Managed Health Services (MHS) is the latest payer to create payment policies aimed at keeping patients from making emergency department visits for “non-emergency” conditions.
Beginning February 1, 2018, MHS, which serves as one of four managed care entities (MCEs) that facilitate the Hoosier Healthwise, Healthy Indiana Plan, and Hoosier Care Connect programs, will be evaluating all Level 4 and Level 5 ER visits to determine if “the final discharge diagnosis appearing on the bill indicates a lower level of complexity or severity” than was submitted. If so, they will auto-adjudicate the claim at the payment rate for 99283.
The only recourse for providers is to appeal the claim “by providing evidence for medical complexity of procedures performed.” At the same time, the payer also reminded providers of their “responsibility to perform the medical screening examination.”
Anthem, another of Indiana’s MCEs, utilizes a similar policy with their Hoosier Healthwise, Healthy Indiana Plan, and Hoosier Care Connect plans. In their case, Anthem uses an ER Auto-Pay List to determine what gets paid and how. If a diagnosis is not on the list, the claim is subject to Anthem’s “prudent layperson review of the medical record.” If upon review Anthem determines that the patient’s condition was not an emergency, then they will reimburse the physician for a screening fee, which is the equivalent of a level 99281 service or around $16.
For more information about the new MHS policy, review the December 7, 2017, announcement on the MHS website.
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