Medical Billing for Urgent Care & Emergency Departments: Specific Challenges and Solutions

In today’s fast-paced healthcare environment, urgent care centers and emergency departments (EDs) play a vital role in delivering immediate care to patients without the need for appointments. However, the nature of their services—unscheduled visits, high patient volume, and complex triage—also creates distinct billing challenges.

Whether independent or hospital-based, these care centers face significant hurdles such as out-of-network claims, denials due to improper documentation, and compliance with ever-evolving billing laws like the No Surprises Act. This blog explores the common billing issues in urgent care and EDs—and the practical solutions that can improve reimbursement accuracy and cash flow.

Urgent Care vs Emergency Department Billing: Key Differences

Though both are designed to handle acute medical conditions, urgent care centers and EDs differ in their ownership structures, service scope, and billing models.

Understanding these nuances is essential for correct coding, modifier usage, and payer negotiations.

Top Billing Challenges and Their Solutions

1. High Out-of-Network Patient Volume

Challenge:
Many urgent care centers and EDs see patients without verifying network status. This leads to delayed or reduced payments, patient dissatisfaction, and exposure to No Surprises Act violations.

Solution:

• Use real-time insurance eligibility tools at check-in.
• Clearly communicate network participation and cost estimates.
• Consider partnering with out-of-network negotiation services to secure higher reimbursements post-service.

2. Incorrect or Incomplete E/M Coding

Challenge:
Emergency departments frequently bill using 99281–99285, with levels determined by the complexity of the case. Incorrect code selection—especially the overuse of 99285—can trigger audits or denials.

Solution:

• Train providers on the latest 2023 E/M coding guidelines focused on Medical Decision Making (MDM).
• Perform regular coding audits to validate accuracy.
• Use software with real-time E/M suggestions based on documentation.

3. Modifier Misuse or Omission

Challenge:
Urgent care and EDs often provide multiple services (e.g., E/M + laceration repair) in the same visit, requiring modifiers such as 25, 59, or X-modifiers.

Solution:

• Implement pre-claim edit systems to validate required modifiers.
• Educate providers and billing staff on when and how to apply modifiers correctly.
• Track denials related to modifiers and re-educate accordingly.

4. Uncollected Patient Balances

Challenge:
With rising deductibles and high out-of-pocket costs, urgent care and EDs often face revenue loss due to uncollected balances.

Solution:

• Offer point-of-service collections and real-time estimates.
• Implement mobile payment options and patient portals.
• Use automated billing reminders via email/SMS to encourage timely payments.

5. Missed Revenue from Procedures and Supplies

Challenge:
Clinics often miss billing for injections, IVs, lab tests, or supplies like crutches, which results in revenue leakage.

Solution:

• Train clinical staff to document all billable procedures and supplies.
• Use checklists and charge capture tools in the EMR.
• Conduct monthly charge audits to identify patterns of missed charges.

6. Authorization Delays and Denials

Challenge:
Urgent care and EDs occasionally perform services (e.g., CT scans, specialty referrals) that require prior or retroactive authorization. Lack of documentation or missed deadlines can lead to denials.

Solution:

• Have a dedicated team to track payer-specific authorization rules.
• Use software that sends alerts for post-service auth follow-ups.
• Maintain checklists for authorization on high-risk procedures.

7. Compliance with the No Surprises Act (NSA)

Challenge:
As of 2022, urgent care and EDs must comply with the No Surprises Act, including:

• No balance billing for out-of-network emergency services.
• Requirement to provide Good Faith Estimates to self-pay/uninsured patients.
• Dispute resolution processes for payment disagreements.

Solution:

• Automate GFE delivery and documentation for applicable patients.
• Partner with RCM firms that can manage NSA compliance and Independent Dispute Resolution (IDR) processes.
• Train front desk and billing staff on NSA-specific workflows.

8. Split Billing Complexity in Emergency Departments

Challenge:
Hospital EDs typically submit two claims—one for the facility and one for the provider. Misalignment in coding or duplicate charges can cause denials or payment delays.

Solution:

• Use integrated billing platforms for coordinated claim submission.
• Regularly reconcile facility and professional coding data.
• Establish QA checks to catch discrepancies before submission.

Best Practices to Optimize Billing for Urgent Care & EDs

Conclusion

Urgent care and emergency departments operate in high-pressure, high-stakes environments—but that doesn’t mean billing has to be chaotic. With proper processes, payer-specific strategies, and a team that understands the landscape, your facility can maximize reimbursements, reduce denials, and stay fully compliant.

As the regulatory and payer landscape continues to evolve, it’s more important than ever to have a revenue cycle partner who specializes in emergency and urgent care billing.

✅ Right Medical Billing: Your Partner for Urgent Care & ED Revenue Optimization

At Right Medical Billing, we understand that every second counts—both clinically and financially. Our tailored services include:

• E/M coding validation
• NSA compliance support
• Out-of-network reimbursement negotiation
• Real-time eligibility and claims scrubbing
• Comprehensive AR follow-up and denial management