UCAOA receives many inquiries about the urgent care industry and below are the frequently asked questions along with their answers.
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Urgent care centers generally use the same evaluation and management (E&M) codes as regular physician office visits. The 2012 Benchmarking Study queried the distribution of visits across E&M codes for the first time.
There are nearly 7,100 urgent care centers in the U.S. The urgent care centers that make up this number have been verified manually by UCAOA and provide full-service urgent care medicine (x-ray, lab, extended hours.) There is no other national database, since federal registration is not required. Another cited figure is 9,000 urgent care centers in the U.S., however, this figure most likely includes retail medical clinics along with urgent care centers.
With the continued entry of investor dollars into the industry, and therefore likely continued growth and/or consolidation, it is probable that this list will continue to grow in coming years.
There is nothing in the PPACA that refers specifically to urgent care by name. That said, there are aspects of it that could influence the industry, namely some of the requirements and regulations around Accountable Care Organizations and their formation. It is the conventional wisdom that should the PPACA survive to be implemented, the newly-created pool of insured individuals will fuel significant growth (and perhaps changes) to the urgent care industry - primarily because the existing primary care system is too small to absorb these new patients.
The size of the urgent care industry has only been measured in any real way since approximately 2008, and the approximate growth in the 2008-2010 timeframe seemed to be about 300 centers per year. In 2011 it appeared that that growth rate doubled, but given the constraints on the ability to count centers, that number (600/year) should be used with caution.
Urgent care began, as far as anyone can tell, in the late 1970s and was created to meet a need in a community. The growth from the 70s-80s was slow and steady as the concept of a "doc in a box" that one could see without appointment gained in popularity. Over the next 20 years the industry continued to expand and to gain respect as a viable place to receive healthcare when one could not get into one's "regular" physician.
In general these terms all refer to “urgent care,” which is differentiated from other health care delivery models based on:
Additionally urgent care centers tend to be positioned in high-visibility, consumer accessible locations, have a strong customer service orientation, and focus on getting patients in and out quickly.
Services offered are generally defined by the practice, but there is a baseline of a broad scope of both "primary care" type services as well as more acute care that is beyond the typical primary care office but below the treatment of life or limb-threatening conditions. Many urgent care centers also provide occupational medicine services, and various other ancillary types of care (physical therapy, weight-loss, etc.)
In some communities urgent care centers do formally function as the primary care practice for some of their patients, usually driven by patient demand rather than competitive intent. These practices do handle ongoing chronic conditions and serve as a formal “medical home” for their patients. The 2012 urgent care benchmarking survey asked a variety of questions to have better data on the extent of this in the industry.
The majority of urgent care centers use a "physician-based" model, typically utilizing family practice physicians and emergency physicians. In addition to these primary providers, centers often staff with medical assistants, sometimes registered nurses, and sometimes X-ray technicians. More and more, urgent care centers also staff with physician assistants and sometimes nurse practitioners. There is no "recommended" or "standard" or “perfect” staffing model. This is determined individually by each center and varies depending on the philosophy of the center, the local labor market, scope of practice, state practice laws, and the like.
This number is impossible to provide. We have tried, and the “washing out” of different variables renders a meaningless number. This depends on your location, staffing model, services offered, contracts, rent/buy choices, and on and on. Each owner will need to do the due diligence to determine this for their own center.
Rules/Criteria for Opening
UCAOA provides a Certified Urgent Care designation program to help centers differentiate themselves and to help the industry overall establish a baseline definition for urgent care centers. Currently, Certification is not a requirement for opening in any state. However, some payers are beginning to require it or to accept it in lieu of their own credentialing process.
The Corporate Practice of Medicine Doctrine basically states that corporations cannot practice medicine, that that should be left up to physicians. Therefore, in the states where it applies (California, Ohio, Texas, Colorado, Iowa, Illinois, New York and New Jersey) clinics must be owned directly by physicians rather than a corporate ownership with physician employees. A quick review of the landscape in these states makes it clear that there are legal structures that make it possible to "get around" that doctrine. Corporations interested in owning clinics in those states should work with an attorney to examine this issue.
Primary care offices are often looking to add urgent care to their existing practices, the assumption being that they will be able to charge additional fees for these visits, which is not always the case. The main question for practices interested in doing this is what their current payer contracts say, and what the payer would require to make this addition. Potential requirements are: separate contract, separate providers, separate entrance and waiting area and exam rooms, new Tax IDs, requirement to close and then re-open at later time, etc. There are no laws about this other than what is above in Opening Criteria.
The current conventional wisdom says about $800,000 if you are starting from nothing. That should cover startup costs as well as three months of operating expenses until you start receiving reimbursements from payers. Obviously, every situation is a little different, and you can make some big mistakes and spend a lot more than that. We recommend that everyone considering opening a center either attends live or listens to the recordings of our Comprehensive Clinic Startup course.
As a non-profit, UCAOA does not do consulting but we offer a Virtual Exhibit Hall containing a listing of consultants. These individuals are experienced in urgent care, but are not formally affiliated with UCAOA.
UCAOA has a policy of not endorsing particular vendors. That is not to say that there are not excellent vendors in the urgent care space – in fact, there are many, which is part of why we do not endorse anyone specifically. In each “category” there are several excellent organizations and we would not want to pick one over the other. Each owner needs to evaluate the different vendors individually for their own practice.
Real estate agents can reach out to us to fulfill a classified ad listing, promoting the availability of a certain property or parcel of land for sale. These ads are listed on our web site.
UCAOA maintains a cordial, informal relationship with our colleagues at the American College of Emergency Physicians. We acknowledge that our country’s payment and incentive systems, and requirements of EDs to act as the nation’s healthcare safety net often puts EDs in a very challenging position. We encourage urgent care centers to work cooperatively with their local emergency departments to best meet the needs of their communities in an open-access, low-cost manner. For more information read "Helping Health Care Work Best – The Role of Urgent Care in Today’s Healthcare System."
UCAOA maintains a cordial, informal relationship with our colleagues at the American Academy of Family Physicians. We acknowledge that in some communities there is a “physician shortage” and in some communities that’s not the case, so the strategies for PCPs and urgent cares working together will vary by community. We encourage urgent care centers to work cooperatively with their local primary care to best meet the needs of their communities for no-appointment, non-emergency care.
We do not. We do provide for members only several templates including an empty Excel workbook that helps ensure you have all your bases covered, but we intentionally do not provide amounts in that workbook or a business plan. Experience of hundreds of consultant hours and owners have told us that the prospective owner needs to do the work of developing that on their own if they are truly to be ready to open and run a center.
We do not. Currently, urgent care medicine is not recognized as a specialty (or sub-specialty) by the American Board of Medical Specialties (ABMS) and it is unlikely this will change in the near future because there are some basic criteria the field has yet to meet (primarily a unique body of knowledge AND a critical mass of training programs).
Most urgent care centers bill very similarly to the typical primary care office, using E&M (evaluation & management) codes. In addition, many centers bill urgent care-specific codes such as S-codes and other after hours codes. Note that these must be pre-negotiated in your contracts to be paid, so it is important to get that in up front. Medicare does not recognize the S-codes. For place of service, urgent care does have its own number, POS 20. Use of this place of service should also be in your contract. Medicare automatically crosswalks POS 20 to POS 10 (primary care) so do not be surprised at this.
It is a common misconception that all urgent care patients are “new” patients and can therefore always be billed with “new” E&M codes at a slightly higher rate. Urgent care centers are subject to the same rules for new vs. established patients as every other practice.