The majority of urgent care facilities contract and bill as urgent care, given the higher reimbursement. The numerous other benefits this provides an urgent care operation. Even though it makes financial sense for the minority of urgent care facilities to do so and bill insurance as a primary care practice.
Utilizing POS-20 billing for urgent care has the advantage of creating a reliable record of how frequently urgent care services are only used in a particular market.
The Centers for Medicare and Medicaid Services (CMS) brought the “Place of Service-20” (POS-20), popularly known to as a “Urgent Care Facility,” in 2003. According to its definition, it is a setting other than a hospital emergency room, an office, or a clinic. Whose objective is to diagnose and treat disease or injury for mobile, unplanned individuals requiring immediate medical assistance.
In the absence of exceptional circumstances or particular contract language to the contrary. The majority of urgent care clinics utilize POS-20 since most payer contracts comply with the standards established by CMS. However, if its operating circumstances and market demand it. An urgent care facility also has the option to enter into a contract with and charge a payer as POS-11 (i.e., a “doctor’s office”).
The Urgent Care Association’s 2018 Benchmarking Report provides the following overview of how the urgent care sector addresses this issue: 1
- 86% of urgent care centers offer a “episodic” range of services.
- While just 3% of urgent care facilities are “hybrid” urgent care/PCPs, 8% of urgent care facilities also provide primary care.
- The most frequent justification given for not providing primary care services is commercial contract constraints.
- Similar to this, 81% of bills are POS-20 (urgent care), 4% are POS-11 (PCP), and 14% are a mix of POS-20 and POS-11.
- 11% of urgent care facilities have UC/PCP dual contracts.
In light of those numbers, let’s examine the benefits for an urgent care facility to contract and bill as POS-20. The rare instances where it makes sense to contract and bill as POS-11. The risks associated with using POS-11 when POS-20 is a more sensible and appropriate option.
Reasons to Bill as POS-20 in a Contract
Increased payment. The increased reimbursement is the main justification for billing as POS-20. Contracts for urgent care usually pay more than contracts for primary care when they are available. (Recall that 81% of urgent care facilities charge in POS-20.)
A primary care contract typically pays around 30% less than an urgent care contract. About $115.1 is the average compensation for urgent care. The national reimbursement average is necessarily lower than what is generally observed for a “pureplay” urgent care. Which ranges from $130-$160 depending on the region of the country. Because the UCA benchmarking average includes around 20% of centers billing POS-11 (for reasons we’ll explore momentarily).
As already indicated, primary care contracts invoiced as POS-11 are significantly less. Reimbursement for PCP contracts has been in the $90 range nationally. Which is consistent with and supported by statistics provided by the American Academy of Family Practice.
The average payment for an adult primary care visit in Northern Virginia is recorded as $77 in jurisdictions like Virginia. Which is unique in that the state legislature developed a website for reporting health prices and statistics.
This number is even lower than the national average because of a number of factors, including a large and expanding Medicaid population. A large supply of primary care physicians in the Washington, DC metropolitan area. The regional growth of managed care organizations, which lower reimbursement rates.
Greater operational expenses. Compared to a primary care office, an urgent care facility has a larger scope and different operational requirements, which results in higher operating expenses. It is vital to negotiate for the larger reimbursement that comes with invoicing POS-20 in order to maintain the business and stay profitable. Some of the higher running costs include the following:
Since visibility is the main driver of volume in urgent care, it is necessary to increase visibility. Primary care offices can be hidden away in less expensive office buildings. However, in order to draw ambulatory patients off the street, urgent care billing centers must be located in high-traffic, retail areas.
Due to the exposure and traffic they generate, the bigger common spaces and parking lots. Retail complexes require more maintenance on their landscape, hence their rent is greater than that of office buildings. Furthermore, the taxes on larger properties are greater.
Conclusion
The main advantage of billing POS-20 for urgent care is that it creates a reliable record of how frequently urgent care services are used in a particular market. Which supports a larger reimbursement for all nearby clinics. Additionally, when negotiating higher rates during contracting, the institution’s obvious designation as an urgent care center serves as justification for the higher operational costs of a walk-in clinic.
There are, however, a very small number of legitimate occasions in which an urgent care would bill POS-11, and such instances are extremely rare. Therefore, POS-20 is often the best choice to support a successful urgent care business.
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