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Urgent care centers are a great alternative to going to the emergency room or are convenient if you can’t get a same day appointment with your physician. They can help you with common ailments like ear infections, the flu and strep throat as well as things that are a little more complicated like cuts or simple fractures. Urgent care centers cannot help with trauma cases or larger issues that require hospital care. These centers are usually staffed by doctors with a primary care or emergency room background and will also employ some physician assistants or nurse practitioners that will work under these doctors’ supervision.
Urgent care centers have become a popular choice for quick care and the number of these centers has grown substantially over the last ten years. As urgent care centers have grown in number, so have the challenges they face with regulations and legal issues. Our attorneys can help urgent care centers with any of the following issues:
• Splitting fees
• State and federal anti-kickback statutes and Stark Law
• Audits by private insurance companies, RAC, ZPIC, OMIG, or MAC
• Compliance with HIPAA, Stark, EMTALA and various other state and federal statutes and regulations
• Medicaid and Medicare regulation compliance
• Fraud and abuse investigations by the government
• Issues with business management including forming corporations, mergers, internal compliance, purchasing practices, setting up practices, contracts with physicians and sales
• Getting accreditation and credentialing
New York Urgent Care Regulations
Regulations in New York require that urgent care center to be separated from emergency room care. The term of “urgent care” should only be reserved for physicians that treat minor traumas and periodic conditions while emergency services will be reserved for major trauma and those life threatening and disabling conditions. Urgent care centers may see unscheduled walk-in visits and also provide care for the following:
• EKG and X‐Rays
• Lab Services and Phlebotomy
• Oral, sublingual, subcutaneous, intravenous, intramuscular, IV fluids and respiratory medication administration
• Specific laceration wound stitching
Additionally, urgent care centers in New York are required to use “Urgent Care” on their signs and their business names plus on their websites and informational materials. They cannot every use the word “emergency” as emergency care services need a special license from the government.
Accreditation of Urgent Care Providers in New York
Doctors who are interested in providing urgent care services in New York must fill out an application and be approved by the Health Department. If you are an existing health care provider that fits the requirements of New York Public Health Law Article 28, this includes hospitals and nursing homes that wish to offer urgent care services, you must go through a limited review by the Health Department. Private doctor’s offices can also offer urgent care services but they must become accredited or certified by a Health Department approved organization or they can become an Article 28 provider. Our attorneys can help medical providers obtain Health Department approval and accreditation.
Medicaid, Medicare, Commercial Payor Audits and Over payments
As urgent care centers have grown and the number of people they have treated have increased, urgent care itself has become increasingly scrutinized by Private Payor Auditors, Medicare and Medicaid. Over payments tend to result in insurance audits and can even lead to certain sanctions that include being excluded from Medicare and Medicaid. The most common issues that auditors focus on are:
• Billed for services that were not authorized by the Operating Certificate
• Billed for services that were denied because of lack of medical necessity
• Identified provider incorrectly on the claim
• Use of incorrect diagnosis codes
• Failed to provide adequate explanation of services
• Orders were not signed by a qualified practitioner
Avoiding accidental errors, keeping correct billing practices and avoiding legally questionable activities help to create a successful compliance plan that can be implemented and followed. Our attorneys can help urgent care practices with creating these compliance plans and can help protect them through any stage of working with Medicare, Medicaid or through the commercial payors audits and appeal processes.
Our attorneys can also help urgent care centers with the negotiating and drafting of employment agreements. Our background of hospital and physician contracts allow us to recognize potential issues that could become future problems for an urgent care center if it is not addressed when the contract is written and negotiated including non-solicitation and non-compete provisions and assigning audit risk.