Experience. Integrity. Advocacy.
Experience. Integrity. Advocacy.

UnitedHealthcare Increases Scrutiny of Facility Emergency Claims

As of March 1, 2018, UnitedHealthcare began using their Optum Emergency Department Claim (EDC) Analyzer tool to evaluate facility ED claims and then deny or reduce payment for services they deem to be incorrectly coded.

According to a UHC Network Bulletin, the proprietary algorithms will evaluate the appropriateness of E/M coding levels by looking at data such as the patient’s presenting problem, diagnostic services performed during the visit, and associated patient co-morbidities.

For now, the new policy affects in- and out-of-network claims for patients covered by UHC Commercial and Medicare Advantage Plans and select UHC Community Plans. As well, the policy currently focuses only on facility ED claims that are submitted with level 4 (99284, G0383) and level 5 (99285, G0384) E/M codes, though not all level 4 and 5 ED claims will be evaluated. The policy excludes the following:

  • Admissions from the emergency department.
  • Critical care patients.
  • The patient is less than 2 years old.
  • Claims with certain diagnosis that when treated in the ED most often necessitate greater than average resource usage, such as significant nursing time.
  • Patients who have expired in the emergency department.
  • Claims from facilities whose billing of level 4 and 5 E/M codes does not abnormally deviate from the EDC Analyzer tool determination.

If a denial or payment reduction is made, facilities can file reconsideration or appeal requests if they believe the originally submitted higher level E/M code is justified. Comparing billed codes and expected reimbursement with actual payments and applied codes on EOBs will be crucial for providers to ensure any denied or reduced claims are quickly identified and appealed.

For now, professional claims are not affected, though Ronald Hirsch, MD, FACP, CHCQM, vice president of the Regulations and Education Group at R1 Physician Advisory Services, says emergency physicians shouldn’t get too comfortable.

“Although provider coding of their visits is not yet a target of UHC’s algorithm, you should warn your physicians that it may happen,” Hirsh writes in a recent RAC Monitor article. “One way they can start helping is to ensure that they are including documentation of all comorbid conditions that they considered when evaluating the patient, determining the necessary ED treatment and testing, and deciding on their disposition.”

For more information, review the December 2017 UnitedHealthcare Network Bulletin which outlines the new policy.

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Charity Singleton Craig

Charity Singleton Craig is a freelance writer and editor who provides communications and marketing services for CIPROMS. She is responsible for creating, editing, and managing all content, design, and interaction on the company website and social media channels in order to promote CIPROMS as a thought leader in healthcare billing and management.

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