Medical Billing

Billing for Urgent Care: A Comprehensive Guide to Understanding when To Use Urgent Care Billing

Billing for urgent care A comprehensive guide to understanding when to use urgent care billing

As a practitioner, your practice is prospering while you have enough patients to treat and you’re managing your revenue cycle management solely. Besides, you work dedicatedly and hire other practitioners to cope with the additional burden of healthcare provision, but your profit margin is still not reaching the point where you have expected it to be.

This may be because of the financial leakage in your billing for urgent care and primary care procedures. Here’s how you can boost your profit margin by just knowing some basics of billing for urgent care.

The process of billing for urgent care

The Centers for Medicare and Medicaid Services (CMS) dedicated POS – 20 (a place of service-20) in 2003, also designated as Urgent Care Facility. According to CMS, the place is defined as; a location distinct from a hospital emergency room, an office, or a clinic, whose purpose is to diagnose and treat illness or injury for unscheduled, ambulatory patients seeking immediate medical attention.”

Insurance companies and almost all the aligned payers need to comply with the guidelines presented by CMS. However, when the contract language is missing, the urgent care facility is compelled to use POS-20.

Urgent Care Billing at your front desk

Also, urgent care facilities can make a contract or make the bills as POS-11 (which is used for the services received at the doctor’s office). But they are only capable of using POS-11 if the operational situations of the healthcare market allow it.

The gap between the deliverance of primary care by the aligned provider and the emergency room facility at a hospital is efficiently filled by the urgent care clinic in healthcare systems. This is why its popularity has soared in the past few years dramatically and is assumed to be worth over $26 billion by the end of 2023.

As a medical practitioner, to command over procedures of billing so you increase and optimize workflow for the maximum returns would be made possible.

Urgent Care Billing at your front desk

Like revenue cycle management, urgent care billing is an important cycle that starts spinning from the front desk. Creating effective and efficient financial policies that begin from the first visit, would create greater chances to increase your revenue and prevent your profit from revenue leakage by the collection process which is quite costly.

At urgent care clinics, patients can have medical care right on the spot, there’s no such system of pre-visit appointments. However, at the front desk, a patient would need to provide basic information in case of walk-in appointments. It is called a registration process. This information may include;

  • Patient’s demographic information including address, name, birth date, and the health condition for which the appointment would be initiated.
  • Details of the insurance provider including the primary insurer and the policy number.

The information taken at the front office helps in the registration process and facilitates the proper maintenance of electronic health records – EHR. An EHR is an electronic database where patients’ history and health information are maintained. Once the patient is admitted to the urgent care facility, the healthcare provider and staff work to update the EHR with the notes, recommended treatment, health condition, physicians’ suggested procedures, prescriptions, and much more.

An updated EHR with complete and updated information makes the urgent care billing process much easier. The information taken at the front desk is also important to gauge if a patient has visited in the past or is a repeat visitor. This is why the information at the front office is important on every visit.

Financial responsibility information

At an urgent care facility, the staff is too occupied with making arrangements for patients. This is the reason they are not always available for the confirmation of healthcare insurance plans that patients mention at the front desk. This pre-authorization service is usually managed at hospitals and private practices.

For this, patients are required to have complete information about their insurance plans and if they are covered for emergency visits or walk-in medical appointments.

Due to the over-occupancy of the staff, patients need to sign an affidavit to incur financial liability before they receive medical service.

Following up with patients after medical visits

No matter where the patient has received medical services, the front office of every medical facility must update, record, and add the information necessary in the EHR. The information added in the EHR helps in the creation of accurate billing and facilitates the claim submission and collection of reimbursements from patient insurers.

How is urgent care billing associated with Medicare

Claim transmission

Once the medical process is completed and all the procedures rendered are coded, they are checked thoroughly so as to check compliance with the required federal or CMS guidelines.

With this, the final step of the billing process is to send the claims to the insurance provider. The claim or the bill that the insurance company receives has all the information regarding the procedure a patient had insured from a certain physician or a hospital facility. The claim also has the information for the associated charges, the diagnosis, and the procedure. An accurate claim without errors, complying with the requirements, will ensure that the provider will receive the full and timely reimbursements.

For an expedient way of lain processing, most of the providers use electronic claim submission software which authenticates every detail they provide. Typically, electronic software will help providers to record patients’ information for accurate claim reimbursements.

How is urgent care billing associated with Medicare?

Generally, when a patient visits an urgent care facility, the staff or the provider are likely not sure about the length of the procedure and the post-visit medical services that the patient might need. This is why billing urgent care can bill more than the estimations using the S codes which recognize the need for medical treatment that will cost them more.

Centers of Medicare and Medicaid Services – CMS are not likely to pay for the services taken from urgent care. This is because the errors and claim denials make it hard for the providers to get reimbursements on time.

Medicare uses the code S for the claims of urgent care (POS-20). But the code doesn’t stop Medicare officials from processing it as urgent care, they keep them processed as primary care and use codes POS-10 and POS-11.

Primarily, Medicaid does reimburse the services taken from urgent care but they still do not process the bills for urgent care services that are naturally high in cost and are provided at walk-in appointments. Hence, providers require their profit to reach a maximum amount and keep the revenue cycle running, they need to maximize the number of privately insured patients.

How does urgent care billing affect the process?

For the efficient handling of urgent care billing, you have two main options to look for;

  • Have an in-house team of billers and coders
  • Outsource the billing process to the medical coding experts

However, both the options will cost you more to curate software licenses and other requirements for the process. Plus, they’ll need complete information about the billing process as they work closely to monitor your financial claims.

While you may rethink outsourcing your revenue process, it also needs to keep in mind that an in-house team can be more expensive. You will not only be providing space and salary to the in-house employees but the additional benefits and perks. In addition, an unexpected absence of an employee can seriously affect the process.

These are some of the main reasons why providers are more inclined towards outsourcing their important tasks for which they will be bounding their businesses for a longer time in the future.

The process of billing for urgent care

Why is it beneficial to outsource your urgent care billing?

An efficient and accurate claim process plays an important role in timely reimbursement and maintaining a smooth revenue cycle. And when you outsource the billing service, it will help optimize resources and get a clearer picture without allocating resources in resubmitting and denials.

  • When you outsource your billing services, it will help you take care of your billing needs round the clock without expecting an absence of an employee for any unforeseen reason.
  • Outsourcing will allow your employees to engage themselves in patient care profoundly without having the burden of multitasking.
  • Outsourcing the billing process to credentialing services will release the burden of reminding your patients of the outstanding bills. They are more efficient in collecting delinquencies as compared to in-house teams.
  • It saves costs and software along with the space needs
  • Urgent care also chooses to outsource its billing process as they find it more convenient and easy to approach. This is because the outsourcing billing agent will do all the data entry regarding the claims and rejections, patients’ data, reminding and sending the bill reports to patients. With EHR interoperability, data transfer has become more seamless.
  • It allows your in-house staff to deliver patient-focused services with evidence-based compassionate care which eventually attracts more customers to the door and the existing ones will keep coming.
  • The outsourcing billing process will also reduce the burden of coding and billing errors. The error-free billing will allow practitioners to have two types of advantages. First, they make the process more efficient and streamlined without putting the practice worries of submitting, calculating, and evaluating the claims into practice, resulting in more collections. The second advantage is they ensure that the practice complies with the regulatory requirements from the agencies like CMS and the Office of the Inspector General. This is because non-compliance with any regulatory agency can bring serious monetary penalties and eventually can affect your revenue cycle management.

The pros and cons of choosing urgent care over primary care

While we have been discussing things according to a provider’s point of view, let’s see what the patient’s view is for the urgent and primary care clinics.

There are some advantages and disadvantages to both and the following discussion will weigh in making a comprehensive decision on whether primary or urgent care clinics are better for you or your family.

The Pros

  • The main advantage of urgent care clinics is that the patient doesn’t need an appointment for medical care but they can just walk in and have complete medical care.
  • There are no specific hours for urgent care units. They are open all day and night hours. Mostly, they are open at weekends as well. So when you are juggling with the family and work all week, you can attain medical help at any time on the weekends when your private doctor isn’t available.
  • Also, when you reach any urgent care clinic, you can witness that you don’t have to wait for long hours compared to a private clinic. This is one of the major things to consider when people have less spare time on weekends/weekdays amidst several responsibilities.

The cons 

  • One of the cons that urgent care clinics relate to is that they cannot provide life-saving care. If there’s an emergency health situation such as a heart arrest or accident, patients need to find an emergency room for prompt treatment. If you or your loved one is in a health emergency, urgent care clinics will not likely provide you the treatment, as an ER (Emergency room) is designated for such issues.
  • Unfortunately, ER will be a costly experience if the family in need of emergency care is financially unstable. If they have been applied for debt and they will take time to arrive, then urgent financial measures would be taken. The cost of an ER would be double the price of an urgent care clinic.
  • You may not see the same doctor again when you visit an urgent care clinic for months. The new physician might not gauge your health history.
  • Many critics perceive this as a great disadvantage as they doubt that the patient would not receive the same healthcare standard no matter if the new physician has all the previous health records.


Whether you opt for an urgent care clinic or primary, the billing and coding for the treatment a patient incurred follow the same procedure. As for providers, whether they outsource the billing or keep it in-house, compliance with the regulatory guidelines is important.