Wiki Urgent care billing-NPP or a physician

[MnTwins29]

While performing an incident-to audit on our NPP's, I discovered that the services rendered in our urgent care facilities were not billed under the NPP or a physician, but instead as "Urgent Care Center" with its own NPI. Is this acceptable? It feels like the same as hospitals, but hospitals would be doing that for technical charges, not professional, correct? I think this is fine...but would like to hear from someone who is more familiar with urgent care than myself. Thank you!

 

[kevbshields]

I was under the impression that some types of urgent cares were "facilities," while others were treated as physician offices. This has even washed over into my health care consumer life. The health insurance I have has an "urgent care center" cost share that is intermediate, between a clinic and a facility. Yet, when I visit a specific urgent care center close to my home, they bill as physician office (evidently), and I pay only the clinic fee.

This probably does not help much. How were the claims you were auditing transmitted--as UB or 1500?

 

[MnTwins29]

Used a CMS-1500. I too am confused about it as a consumer - for the SAME facility that I have visited twice, I was once charged a $35 copay (same as the ER copay under my coverage) and the second time at the same place, I was charged $15 (office visit). Huh???

Will continue digging - thanks for your help.

 

[mitchellde]

I would check with the state licensure laws in your state, there are specific requirements that must be met to be called an urgent care clinic vs a doctors office. Hold their feet to the fire if they advertise as an urgent care clinic and then charge as a physician office! One of the things being looked at this year is billing the appropriate POS due to reimbursement differences.