Top 5 Challenges in Urgent Care Self-Pay Billing and How to Solve Them

The “self-pay” demographic is growing rapidly for urgent care centers. This group includes not only the 28 million uninsured Americans but also a rising number of functional self-pay patients, those with high-deductible health plans (HDHPs) who choose to pay out-of-pocket to avoid complex insurance hurdles.

However, billing for these patients is not as simple as “cash for service.” Strict federal regulations, particularly the No Surprises Act, have introduced significant administrative hurdles.

Here are the top 5 challenges in urgent care self-pay billing and how to solve them.

Urgent Care Self-Pay Billing: Challenges and Solutions

The sphere of self-pay billing is growing, yet it has special challenges. Knowing those barriers and applying effective strategies will ensure you are in compliance, increase collections, and keep patients satisfied.

1. Compliance with the No Surprises Act & Good Faith Estimates (GFE)

Every uninsured or self-pay patient is required to be provided with a Good Faith Estimate (GFE) prior to the services beginning, as of January 1, 2022.

The Challenge:l

There are a lot of walk-ins in the urgent-care centers. It is difficult to make a detailed, itemized GFE in real time. Providers should provide the GFE within three business days of a request or scheduled appointment.

Solution:

• Use pre-built CMS GFE templates.
• Train front-desk staff to gather necessary info quickly.
• Provide digital GFEs through email or text in order to accelerate compliance.

2. The “$400 Rule” & Patient-Provider Dispute Resolution (PPDR)

Patients may invoke the PPDR process in case the final bill is more than the GFE by $400 or above.

The Challenge:

Emergency care is unpredictable. Even a mere cough might result in X-rays, nebulizer services, or lab tests, which will bring the bill past the $400 mark. This has the potential of adding additional administrative charges and revenue loss.

Solution:

• New services that have been added should be included in estimates during the visit.
• Inform patients that estimates may vary depending on the need for care.
• Record all the services to support the estimate.

3. Real-Time Price Transparency vs. Rapid Care

The federal price-transparency regulations demand that the clinics be able to post standard charges in a machine-readable format.

The Challenge:

Tiered pricing (e.g., Level 1: Simple, Level 2: Complex) is commonly applied in urgent-care centers. Unless the documentation is comparable to the quote given at the front desk, patients will feel betrayed, thus resulting in conflicts and delayed payments.

Solution:

• Have a web-based list of self-pay bundles.
• Train employees to quote within a short time and get it right.
• Automate common procedure pricing using EMR software.

4. Coding Complexity: E/M Levels and “S-Codes.”

Insurance coding is different from self-pay coding. A flat fee is represented using HCPCS S-codes in some urgent-care centers.

The Challenge:

S-codes are not recognized by Medicare and federal programs. Using the wrong code can lead to legal liability or denial of payment.

Solution:

• Even flat-fee visit document E/M levels.
• Compliance with the use of standard CPT codes.
• Make the train staff familiar with the differences in coding between self-pay and insured patients.

5. Front-End Collection Hurdles

Once the visit is done, it is significantly more difficult to collect payment. Studies indicate that collectability drops nearly 50% once patients are out of the facility.

The Challenge:

Front-desk employees should communicate GFEs, provide payment options, and receive deposits without compromising the efficiency of patient flow.

Solution:

• Introduce Time-of-Service (TOS) collection policies.
• Take an initial fee and balance out post-visit.
• Provide post-visit options and/or Card on File.

Checklist for Urgent Care Managers

Let Us Simplify Your Self-Pay Billing

Self-pay billing may prove difficult. Particularly as a higher number of patients pay out-of-pocket, and the strict regulations, such as the No Surprises Act. Clinics need to make transparent cost estimates, maintain the price, and ensure the efficient collection of payments. 

Partnering with experts like Tennessee Billing Solutions helps urgent care centers simplify billing, stay compliant, and improve collections.

Contact us today to learn how we can streamline your self-pay processes and make billing easier for both your staff and patients.

Frequently Asked Questions

1. What is a Good Faith Estimate (GFE)?

A GFE is a written list of estimated costs of self-pay or uninsured patients. It has to be in accordance with the No Surprises Act.

2. When does the $400 rule apply?

If the final bill is higher than the GFE by more than $400, patients have the right to challenge the expenses via the Patient-Provider Dispute Resolution process.

3. Can self-pay patients get price transparency online?

Yes. Clinics are required to make standard charges available in machine-readable format and should provide online menus for common self-pay services.

4. What happens if coding is incorrect?

False coding may result in reimbursement or even legal action, or audit red flags. Record E/M levels even in flat-fee visits.

5. How can urgent care centers improve collections?

Utilize Time-of-Service collection, collect deposits upfront, provide payment plans, and have clear communication with patients.