Do I market my clinic to the insurance carriers as a primary care practice, an urgent care practice, or a blended practice? That is the question.
There are a lot of variables to consider when making this decision. You need to make sure you are opening up a center that is well aligned with the needs of your community. Analyzing your market and the competition around you should assist in making this important decision. Another factor to weigh in on is the difference in payor contracting. Below is a list of requirements and contract language that you could typically expect to find within each contract type. With the below information, which path will you head towards?
Typically, there are two contracting paths for urgent care centers.
Primary Care Path
- Lower co-payment typically applies
- Requirement to take a certain amount of membership – members are assigned to your practice
- Hospital admitting privileges are required at a participating hospital Physicians may be required to treat patients in the ED as a “No Doc”.
- Reimbursement is typically lower than urgent care reimbursement
- Requirement to be available to patients 24/7
- Individual provider credentialing most always required – non-payment for services until the provider is fully credentialed
- Reimbursement is typically fee for service or capitated
- Individual providers are typically listed in provider directories and marketed – not the facility (makes your practice hard for patients to find)
- Payors will typically accept the following provider types at a primary care clinic: General practitioners, Family Practitioner, Internal Medicine, Pediatrician
- Emergency Medicine providers have difficulty obtaining PCP contracts and getting credentialed
- It is frowned upon and most times prohibited for the clinic to have “urgent care” in the name of the practice. This is confusing to patients.
Urgent Care Path
- Higher co-payment typically applies
- Depending on the contract, individual provider credentialing may not be required
- Potential for flat rate reimbursement (which is not generally preferred)
- No hospital privileges required typically (No Hospital credentialing fees and maintenance of hospital privileges)
- Reimbursement is typically higher (5%-10%)
- Urgent care facility is listed in provider directory, not individual provider – which is a benefit for when patients are looking for a participating urgent care.
- Requirement to be open for business a certain number of hours after 5pm
- Saturday and Sunday hours are generally required
- May require urgent care accreditation or certification
- May exclude any primary care (physicals, follow up, immunizations, etc.)
- May require provider to forward information to patient’s PCP for follow up care
- Payors will typically accept the following providers: General Practitioners, Emergency Medicine, Internal Medicine, Family Practice
- Cannot generally add primary care services under an urgent care contract (per the payors). Possible Reasons: The payment terms are typically different, claims adjudication system cannot handle dual specialties and differential payment terms under one address affiliation, etc. For these reasons the payor will either decline a request to add PCP to an urgent care agreement OR will require a separate Federal TIN and separate contracts for the primary care services.
What if I want to run a blended practice (i.e., both primary and urgent care services)?
If contracted as a PCP:
- If the payor contract is a PCP contract: The clinic can generally operate as a walk in practice (unscheduled visits) and treat primary care patients without obtaining dual contracts.
- There will be no payment differential from the payor between what you would consider PCP and urgent care services.
- There is a possibility to bill for the after-hours, weekends, and evenings codes under this agreement type, to get additional payment for urgent care visits. There is no guarantee the payor will reimburse for these codes.
If contracted as an urgent care:
- Cannot generally add primary care services under an urgent care contract (per the payors). Possible Reasons: The payment terms are typically different, claims adjudication system cannot handle dual specialties and differential payment terms under one address affiliation, etc.
- For the above reasons, the payor will either decline a request to add PCP to an urgent care agreement OR will require a separate Federal TIN and separate contracts for the primary care services.
A final option to consider is contracting as both a primary care and as an urgent care. This would involve separate Employer Identification Numbers (EIN), addresses, providers, contracts, etc.
Bottomline, you need to consider your long-term plan for growth at the beginning of your venture.
