According to a UnitedHealthcare Network Bulletin article published in January 2009, UnitedHealthcare will implement a new policy that will not separately reimburse the following urgent care S codes in any place of service. This policy was stated to be effective second quarter of 2009, so you may begin to see denials shortly.
If you have not already experienced denials, you should expect denials from UnitedHealthcare shortly for the following codes:
Compared with the cost of rendering the same services in a typical primary care physician office, the cost for outwardly identical services is generally be significantly higher when these services are rendered in an urgent care clinic. The reasons for this increased cost include:
You may want to contact UnitedHealthcare to explain to them that as an urgent care center, your facility incurs costs that are not incurred in the typical physician office. Compared with the cost of rendering the same services in a typical primary care physician office, the cost for outwardly identical services is generally significantly higher when these services are rendered in an urgent care clinic. The reasons for this increased cost include:
Note: UnitedHealthcare may point out that Medicare currently does not pay on these codes. Of course, S codes are never reimbursed by Medicare, and these codes have been specifically made to enable private payors to reimburse healthcare providers for costs not included in the CMS RBRVS system. It is important to note that very few (if any) urgent care centers can deliver true urgent care services at Medicare rates, and that this code was specifically created for payors in the private sector to compensate urgent care centers for these increased costs.
http://www.urgentcarenews.com/vol1_1/S9088.php
- S9083 Global fee urgent care centers
- S9088 Services provided in an urgent care center (list in addition to code for service)
Compared with the cost of rendering the same services in a typical primary care physician office, the cost for outwardly identical services is generally be significantly higher when these services are rendered in an urgent care clinic. The reasons for this increased cost include:
You may want to contact UnitedHealthcare to explain to them that as an urgent care center, your facility incurs costs that are not incurred in the typical physician office. Compared with the cost of rendering the same services in a typical primary care physician office, the cost for outwardly identical services is generally significantly higher when these services are rendered in an urgent care clinic. The reasons for this increased cost include:
- Downtime: Because an urgent care sees patients on an unscheduled basis, patient flow in the urgent care center is unpredictable and uneven. Thus, the urgent care center will sometimes be open for hours, while no patients walk in. So although the center is incurring the expenses of salaries, benefits, heating/cooling, etc., the center is generating no revenue during these hours.
- Higher Wage Costs: Primary care physician offices generally are open for patient visits during the day on weekdays. On the other hand, urgent care centers deliver services on weekends, holidays and evenings. Thus, in order to hire qualified staff, an urgent care center must offer higher hourly compensation. This results in the urgent care center incurring higher wage costs for the same staffing levels as a primary care office.
Note: UnitedHealthcare may point out that Medicare currently does not pay on these codes. Of course, S codes are never reimbursed by Medicare, and these codes have been specifically made to enable private payors to reimburse healthcare providers for costs not included in the CMS RBRVS system. It is important to note that very few (if any) urgent care centers can deliver true urgent care services at Medicare rates, and that this code was specifically created for payors in the private sector to compensate urgent care centers for these increased costs.
http://www.urgentcarenews.com/vol1_1/S9088.php
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