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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.”


Chuck Buck

Chuck Buck is the publisher of RACmonitor and is the program host and executive producer of Monitor Monday.

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