Alan Ayers, MBA, MAcc, President, Urgent Care Consultants
Unlocking New Revenue from Ancillary Services
As an urgent care operator, maximizing utilization of your assets is key to success. Your on-site X-ray suite is a significant investment, but what if you could leverage it beyond your own patient base to serve neighboring practices, like a nearby primary care physician (PCP)? This is a common scenario, but it raises important questions about workflow, billing, and compliance, especially when the urgent care (UC) and PCP operate under different tax IDs.
A frequent question is whether a PCP’s patient must be registered and evaluated by a UC provider just to get an X-ray. This creates a clunky workflow, a poor patient experience, and potential billing headaches. For instance, it could trigger an unnecessary UC copay and conflict with payer contracts that bundle imaging services with a full evaluation and management (E/M) service.
A more elegant and compliant solution is the purchased diagnostic test model.
In this arrangement, the UC provides only the technical component (TC) of the X-ray service on behalf of the PCP. The workflow
is streamlined:
- The PCP orders the study and remains the treating physician, retaining clinical responsibility.
- The UC performs the imaging-only service without a separate E/M visit or copay collection.
- The PCP bills the payer for the X-ray, and the UC simply invoices the PCP monthly at a fair-market value (FMV) rate for each study performed.
To implement this correctly, a formal services agreement is essential. This agreement protects both parties and ensures compliance with regulations like Medicare’s anti-markup rule. A comprehensive checklist for drafting this agreement should define crucial terms, including:
- Parties and Purpose: Clearly identifying the UC as the TC provider for the PCP.
- Billing and Compliance: Establishing FMV rates that do not vary by referral volume and outlining how the PCP will bill payers.
- Clinical Responsibility: Confirming the PCP obtains necessary pre-authorizations and communicates results to the patient.
- Operations: Defining image storage, PACS access, and turnaround time expectations.
By structuring a purchased-test relationship, you can transform your X-ray suite from a cost center supporting only your UC into a revenue-generating asset that serves your medical community.
Structuring these arrangements properly is crucial for compliance and profitability. If you have questions about urgent care planning and operations, schedule a discovery call today.