UnitedHealth says it will use proprietary software to deny claims.
EDITOR’S NOTE: The topic of this article was previously covered by RACmonitor on separate occasions in 2017 and 2018.
To welcome the new year, UnitedHealthcare (UHC) has announced that starting April 1, 2020, they will use a proprietary software program to evaluate all professional claims submitted for emergency department visits with the Level 5 evaluation and management (E&M) code 99285.
According to guidelines from the American Medical Association (AMA), a Level 5 emergency department visit requires a comprehensive history, a comprehensive examination, and medical decision-making of high complexity. In order to determine the complexity of medical decision-making, the AMA guide requires a review of the number and complexity of problems considered, the amount and/or complexity of data reviewed, and an assessment of risk.
Yet the UHC announcement notes that the Optum Evaluation and Management Professional (E&M Pro) tool will determine the “correct” code-based solely on the patient’s age and the diagnoses submitted on the claim – and if the tool determines that the submitted diagnoses justify a lower-level code, the claim will either be automatically adjusted to the lower-level code or denied “based on the reimbursement structure” in their contract.
UHC justifies this policy of automated downgrading by noting that it is “part of our continued efforts to reinforce accurate coding practices,” and that medical records will not be requested “in an effort to reduce the administrative burden of requesting and submitting medical records for review.”
But a little-seen memorandum released by UHC in 2014, titled “Use and Misuse of 99285,” may suggest an underlying motive. The memo describes an increased use of 99285 on emergency department claims in an Arizona plan administered by UHC, and goes on to state that “any improper billing trends will be referred to the Office of the Inspector General (OIG) for further investigation.”
Readers of RACmonitor will recall that in late 2017, RACmonitor editorial board member Ronald Hirsch, MD, of R1 RCM, reported on the UHC plan to use a proprietary tool to automatically downgrade high-level emergency department facility visit claims – and in 2018, Tim Powell, also a RACmonitor editorial board member, took readers on a deep dive into the ED Claim Analyzer that UHC uses.
“While we had a little peek behind the green curtain with the facility fee downgrades, with Tim Powell’s reporting, physicians will have no idea how the UHC E&M Pro tool works,” Hirsch said. “The diagnosis codes submitted on the claim in isolation do not give a complete picture of the medical complexity of the patient, or of the medical decision-making undertaken by the physician.”
Added Hirsch, “I would hope that the emergency medicine physicians and their advocacy organizations would strenuously object to this plan.”
In the last few weeks, I’ve taken several sheepish calls from folks indicating that they received a call from a government agent and proceeded to
Press releases from the Centers for Medicare & Medicaid Services (CMS) are typically rather straightforward, easily summarized as: here’s what we’re doing, why we’re doing
Please log in to your account to comment on this article.
Unlock the keys to bridging the clinical-finance disconnect by transforming your approach to revenue cycle collaboration for superior patient care and financial prosperity!
Join Dr. Ronald Hirsch as he delves into the pivotal connection between case management, utilization review, and hospital revenue cycles, unveiling strategies to enhance communication and align goals effectively. Discover how to overcome hidden challenges hindering seamless collaboration and gain insights imperative for success
During this webcast Dr. Hirsch will breakdown the CMS-4201-F rule and the new federal regulations, how and when they will apply to Medicare Advantages plans.
The CMS Two-Midnight Rule and short-stay audits are here to stay, impacting inpatient and outpatient admissions, ASC procedures, and Medicare Parts C & D. New for 2024, the Two-Midnight Rule applies to Medicare Advantage patients, requiring differentiation between Medicare plans affecting Case Managers, Utilization Review, and operational processes and knowledge of a vital distinction between these patients that influences post-discharge medical reviews and compliance risk. Join Michael G. Calahan for a comprehensive webcast covering federal laws for all admission processes. Gain the knowledge needed to navigate audits effectively and optimize patient access points, personnel, and compliance strategies. Learn Two-Midnight Rule essentials, Medicare Advantage implications, and compliance best practices. Discover operational insights for short-stay admissions, outpatient observation, and the ever-changing Inpatient-Only Listing.
A massive task lies ahead! Now’s the time to start preparing your case management and utilization review teams for successful implementation of changes contained in the 2024 IPPS, OPPS and MPFS rules.
Uncover effective techniques to foster provider understanding of CDI, empower CDISs and coders to customize their queries for enhanced effectiveness, and learn to engage adult learners, leveraging their experiences for superior learning outcomes. Elevate your CDI expertise, leading to fewer coding errors, reduced claim denials, and minimized audit issues.
This exclusive ICD10monitor webcast series will help you acquire the critical knowledge you need to completely and accurately assign ICD-10-PCS and CPT® codes for spinal fusion and other common spinal procedures.
This exclusive ICD10monitor webcast is intended to elevate and streamline outpatient coding for spinal procedures. Our expert presenter, Kim Felix, RHIA, CCS., will provide clear, detailed explanations covering spinal anatomy, spinal procedures, and correct CPT coding practices.
During this exclusive ICD10monitor webcast, inpatient coders will gain a profound understanding of prevalent spinal procedures. They’ll delve into the intricate anatomy, grasp the purpose and method behind these procedures, uncover essential elements within physician documentation, and receive expert guidance, step by step, on constructing accurate ICD-10-PCS codes. It’s the key to enhancing their expertise and ensuring coding precision.
Copyright © 2023 RACmonitor. Powered by MedLearn Media.
