Navigating the Complexities of Contracting and Credentialing in Urgent Care

Contracting and credentialing providers is a complex process that keeps evolving for urgent care. The number of payers involved, rules that vary from state to state, and market saturation make this process even more complicated. But for urgent care clinics, contracting and credentialing is essential to success. Not doing your due credentialing diligence before hiring a provider not only costs you revenue from day one but can result in billing violations that land providers in some pretty hot water.

However, the structure of urgent care can make it really difficult to comply with payer requirements. Let’s break down contracting and credentialing and see what to keep an eye on and how to best stay on track.

The Importance of Credentialing

Credentialing ensures that healthcare providers meet specific qualifications and standards to deliver care – and get paid appropriately. Failing to properly credential providers can lead to severe consequences, including loss of revenue, hefty fines, and even jail time.

The significant impact that urgent care has had on healthcare delivery and economics has brought it under increased scrutiny in recent years from both government and commercial payers. This scrutiny necessitates a thorough understanding of credentialing requirements and the importance of adhering to them.

Common Issues and Misconceptions

One prevalent issue we encounter at Experity is groups not credentialing their providers according to payer requirements and then billing for those providers under other credentialed providers. This practice not only risks financial penalties but also the potential loss of group agreements with payers and even prosecution.

There are several reasons why groups might not credential a provider, including a lack of understanding of the risks, false impressions of requirements, or uncertainty about the provider’s long-term commitment. All of these are exacerbated by industry trends and challenges along with reimbursement and renegotiation obstacles. However, the most common reason is the perceived cost of credentialing.

The Cost of Credentialing vs. The Cost of Non-Credentialing

The cost of credentialing, while it may seem high, is nominal compared to the potential revenue loss from not credentialing. For example, if a provider sees six patients a day without being credentialed, the lost revenue can amount to over $22,000 in just one month and nearly $70,000 in ninety days. On the other hand, credentialing a new provider might cost around $3,000, which is minimal compared to the potential revenue loss.

Industry Trends and Challenges

Payers are not always in line with the way the urgent care industry practices. For instance, how can clinics be expected to credential a provider six to eight months before they open? It’s hard to hire somebody that early in game or in some cases, keep them that long.

And why does a provider need proof of malpractice coverage months before seeing  patients? Finally, considering seasonal unpredictability and volume fluctuations, it’s difficult, if not impossible, to fill shifts unexpectedly under the current credentialing guidelines.

Although it’s challenging, the best you can do is know what you’re dealing with and stay on top of it. Here is a snapshot of challenges related to payer requirements and credentialing:

1. Accreditation requirements: Some payers now require urgent care centers to be accredited before granting new contracts
2. Medicare application delays: New groups or those adding locations may experience delays in Medicare applications
3. Denial of new locations: Established groups may face denial of new locations by payers
4. Physician credentialing: Despite non-physician providers filling more key roles in urgent care clinics, payers often still require a physician to be credentialed as the medical director
5. Frequent changes in requirements: Payers regularly change their credentialing requirements with little notice, making it crucial to stay informed and adaptable

To mitigate the risk, never assume anything. Never assume things are the same today as they were last year when hiring a provider. Work with your team closely — make sure you have current contact information on file with all payers, review payer contracts on a specific cadence and do all you can to be sure you stay compliant.

Need expert help with contracting and credentialing? Contact our Revenue Cycle Management team >>

Reimbursements and Renegotiations

Reimbursement rates for new groups are often lower than they used to be, and even established groups may face amendments with lower fee schedules. This trend is driven by market saturation and the economic impact of urgent care on lower-cost delivery systems like primary care.

To navigate these challenges, it’s essential to:

• Understand the reasons behind declining rates
• Explore alternative revenue streams, such as marketing to employers with favorable insurance plans
• Enhance patient experience to increase desirable volume
• Consider options to reduce reliance on payers

When you are looking at your growth goals, be very strategic. Renegotiations may not be the only or even the best choice when it comes to increasing revenue. Consider marketing to employers in your area that offer employee health insurance from one of your better payers. That’s usually not going be the payer that sends you the most volume: for the payers that reimburse you the best, go out and market to those particular employees.

Final Thoughts and How to Get Help

Contracting and credentialing are vital to the overall health of your practice, impacting both revenue and compliance. Staying informed and working closely with your team can help navigate these complexities. Payers still have a long way to go to fully support the urgent care market, and it’s up to you to educate them and work collaboratively to build a successful contracting and credentialing strategy.

If this is overwhelming or confusing, you can work with an expert to get it right. Experity’s RCM team works exclusively with urgent care, so we understand the exact challenges you’re facing and how to best solve them. You can see what other services our RCM team provides by visiting our product page, or you can request to speak with someone by clicking below.

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