The Top Urgent Care Billing Challenges Driven by the Pandemic

By Monte Sandler, Executive Vice President of RCM Services, Experity
Twitter: @ExperityHealth

The U.S. urgent care industry has been faced with numerous and novel financial challenges throughout the COVID-19 pandemic thus far. Like most industries, urgent care clinics have had to pivot and adapt their business processes and workflows to best navigate new and unfamiliar territory, and this is especially true when it comes to COVID-19 billing and reimbursement.

While having to deal with the lack of available personal protective equipment (PPE) and drastic fluctuations in patient visit volumes, it became increasingly difficult to navigate the financial landscape and stay profitable. Of all the challenges urgent care clinics had to address and overcome over the past year and a half, three consistently plagued the industry.

Three Leading Billing Challenges for Urgent Care Providers

1. Reimbursement for testing and treating uninsured and undocumented patients.

Due to the economic fallout of the pandemic, the U.S. unemployment rate rose to a level akin to that of the 1930s. In April 2020, unemployment rates reached close to 15% and as a result, many individuals and families became uninsured as their healthcare coverage was tied to employment.

Amidst this widespread loss of coverage, the Health Resources & Services Administration (HRSA) established the COVID-19 Uninsured Patient Program Portal last April to provide claims reimbursement to providers, generally at Medicare rates, for testing, treating, and vaccinating COVID-19 patients that are uninsured. The program was hugely important during the first year of the pandemic, as it meant more individuals could get the care they needed despite loss of insurance.

However, for providers, reimbursement for claims submitted through the portal came with numerous problems. Clinics were reimbursed at Medicare rates, but were often spending more money to see patients than was covered by this rate. Claims could only be submitted once, so clinics couldn’t submit claims for new charges associated with a prior claim. Lastly, securing correct identification and information for undocumented patients was difficult, and rejected or returned claims for these patients were hard to resolve as there was no appeal process for corrected claims.

2. Constant changes to healthcare regulations and coding.

Healthcare policies and coding regulations were in constant flux during the pandemic, and especially in the early months. As part of these constant changes, new CPT codes were established for documenting and billing COVID-19-related visits while providers were forced to adopt telehealth processes to mitigate risk by remotely managing patient testing.

The healthcare model that had largely been routinely followed for years quickly became new territory for providers. The learning curve combined with incorrect claims due to new guidelines resulted in more rejected or returned claims that required time spent reworking to receive proper reimbursement. Retraining and reworking existing systems to reflect new codes required time that urgent care clinics couldn’t spare as visit volume increased. Furthermore, guidelines across the continuum varied. Different payers had different telemedicine guidelines, which resulted in disputed claims across the industry and more work for provider offices.

3. Patient confusion around COVID-19 care coverage.

Urgent care clinics felt the effects of patient confusion throughout the pandemic. Patients were afraid and unsure of so much all at once—virus exposure, telehealth options, testing locations, test eligibility, and coverage of COVID-19 services. In addition to meeting the high demand of patients that needed tests, clinic staff had to answer more questions than ever as patients sought clarity and reassurance from their local providers.

While the government confirmed that COVID-19 testing would be free for all, there were caveats that weren’t communicated, including differences in guidelines when it came to basic screenings versus testing those who had exposure to the virus. As a result, patients came to urgent care clinics expecting free COVID-19 testing and care, but some still received bills based on their insurance coverage which caused frustration and billing discrepancies.

As the urgent care industry continues to adapt and evolve in response to the global health crisis, it will be important for clinics to double down on ensuring revenue cycles are healthy and sustainable despite the changing landscape. While reimbursement guidelines have stabilized significantly since early 2020, and clinics have become much more familiar with the latest coding changes, it will likely be a few months until the majority of clinics resolve all COVID-19 claims that are still in limbo and really get revenue cycles back on track following this past tumultuous year in healthcare.