Recent report by Urgent Care Association (UCA) in United States indicate that about 89 million patients visit Urgent Care Centres for treatment annually. The industry is expected to reach $26 billion by 2023. The 2018 Urgent Care Benchmark survey response indicate only 7% of total patients were of the fully cash pay category. 93% users had some form of insurance or other coverage which reflects the importance for high level of billing accuracy and automation of operations. With 8774 centres operating nationwide, and centres openings every day, staff members responsible for coding medical instances, eliminating coding errors and inefficiencies is paramount to their financial success.
The difference between insufficient and erroneous coding is in the former, the urgent care centre does not bill for all services consumed by the patient while the latter is when wrong code has been used while billing. Figure 1 presents revenue leakages due to insufficient and incorrect coding. A coding insufficiency is noticed by the insurance payer when there is a gap in match between services provided and billed. The American Medical Association (AMA) updates the CPT annually and service providers need to ensure the codes used are relevant and audited. Also visit pattern has to be considered while posting a code against services consumed at the Urgent Care Centre. Let us consider an example case for inefficiencies in coding. A pregnant visitor from out of town in her first trimester visits an urgent care centre to measure blood pressure, weight & manage morning sickness adhoc. This could be a service extended by a nurse practitioner and not something the insurance company might reimburse. However, a gestational diabetes screening or anomalies scan in Trimester two would involve a set of blood draws/ tests/scans being ordered. So while coding and for purpose of billing, care should be taken to sufficiently record all procedures conducted in order to ensure bills submitted to carriers or payers are accurate . This will result in lesser claims being rejected.
Urgent Care Centres may experience a loss up to 20% of revenues simply because services were not billed correctly or code entries recorded were incorrect. Lack of correct evaluation of patient‘s billing eligibility, not recording all services extended by care provider in detail and using a fixed number of codes for billing a variety of services are underlying factors that cause revenue leakage through insufficient coding. Studies show that some physicians can stand to loose between 10 and 20% of reimbursement because of incorrect E&M services coding. Typically, reimbursements for service providers are based on match between appropriate CPT coding for the service, diagnosis coding according to ICD codes; and the Centres for Medicare and Medicaid Services (CMS) evaluation of fees according to relative value scale.
Coding errors include upcoding, unbundling, and double billing. An example of up-coding or balance billing will be when the Urgent Care Centre charges for a service not covered under any policy, or in excess of agreed inclusions by the insurance payer. Eg: An asthmatic patient visits an Urgent Care Centre for nebulizer administration, but gets billed for emergency service which might not be covered in his policy. Another area where coding error commonly happens is vaccination administered at Urgent Care Centres. Typically, front desk staff bill just the vaccine code while they should be instead billing for vaccine administration charges too as it will include the cost of vaccine administration. Another common area of wrong billing input is related to patient information. Simple errors such as wrong spelling, spacing or typographic errors while keying in patient information can lead to backlog of claims being reimbursed because insurance companies either seek clarification or outright reject the claim. So Urgent Care Centres end up having to do a lot of reconciliation efforts in the month end.
Front desk staff should ensure the Urgent Care Centre has updated and correct billing information of the patient. If this is missed at the time of patient visits, chances are claims billed to Medicare without new Medicare Beneficiary Identifier (MBI) will be rejected. Claims sent with old Health Insurance Claim Number (HICN) or with wrong hyphens or spaces used will also be rejected from December 2019 onwards.
Charge capture related and coding errors are the main areas that add to revenue leakage. Published industry trends material show that service providers spend an average of $25 to appeal for and rework claims rejected by insurance payers. Further the time spent too is significant at over 30 minutes per claim. However, 90% of these rejections are avoidable in first place by simply ensuring that coding and charge captures are correctly recorded at the time of service by Urgent Care Centre staff. An efficient billing system which picks up codes and patient information correctly to avoid rework and claims directly contributes to arresting revenue leakage.
A well-defined automated billing and coding framework can flag anomalies such as incorrect codes used or invalid patient details being keyed in by the front desk agent. Collection amounts, average encounter reimbursement, amount of claims re-billed, E/M code distribution, days to bill, days in A/R, front desk collection amounts, etc. all directly link to and affect revenue. Smart automated coding can significantly reduce rework, and claims rejection at carrier level in the first place itself. This will ensure revenue booked is accurate and write-offs or adjustments can be reduced during monthly or quarterly reconciliation.