UnitedHealth Group and MEDPAC both reported on the state of emergency departments last week.
Last week, emergency departments (EDs) got some serious national attention.
First, UnitedHealth Group released a study examining costs associated with freestanding emergency departments (FSEDs), and second, there was a call for the Centers for Medicare & Medicaid Services (CMS) to develop formal code selection guidelines for emergency services.
Both news items were reported by Ronald Hirsch, MD during his segment on Monitor Mondays this past Monday.
Emergency departments – both freestanding and hospital-based – treat non-emergent conditions for millions of patients each year at substantially higher prices than physician offices or urgent care centers, according to the report released last week by UnitedHealth Group, “Freestanding Emergency Departments: Treating Common Conditions at Emergency Prices.”
Hirsch, quoting from the report, told audience members that less than 25 percent of such facilities accept incoming ambulances, and they often do not accept Medicare or Medicaid, at least in Texas, where there is a large number of FSEDs. Hirsch said such facilities also tend to be located in metropolitan areas with higher median incomes that are already well-served by hospitals, urgent care centers, and physician offices.
“Their data also indicated that while 8 percent of visits to hospital-based EDs are classified as true emergencies, requiring the care only available in an ED, only 2.3 percent of visits to FSEDs were true emergencies,” Hirsch said. “They (UnitedHealth Group) also report that the costs of these EDs is significantly higher than even hospital-based EDs, with the average cost for a patient with strep throat to be over $2,700, compared with $1,800 in a hospital-based ED and $130 in a doctor’s office.”
In Texas, the average cost of treating common conditions at an FSED ($3,217) is 22 times than that of a physician office ($146) and 19 times more than that of an urgent care center ($167).
As reported here on RACmonitor, major health plans, including UnitedHealth Group and others, have a vested interest in reducing utilization of these FSEDs because of their cost. While the underlying motivation for this study is unknown, it certainly is interesting.
The other ED issue that came up last week has been a topic covered on prior Monitor Mondays broadcasts: the coding and payment of the emergency department facility fee.
“You may recall that the coding for these visits has no official guidelines from Medicare, so it is left to hospitals to develop their own,” Hirsch said. “And apparently, there has been an increase in the number of visits that are coded with higher-level codes, which led the Medicare Payment Advisory Commission (MEDPAC) to discuss this trend at their meeting last week and to recommend that CMS finally develop formal code selection guidelines.”
“Now, of course, nothing happens quickly, but by 2022, we may actually have a formal guideline,” Hirsch added. “But until then, it remains confusing and subject to interpretation.”
The Centers for Medicare & Medicaid Services (CMS) released the Final Rule for the 2025 Medicare Physician Fee Schedule on Nov. 1, which included a
Let me open by saying I am so happy to be here. For those of you who watched the live version of last week’s Monitor
Please log in to your account to comment on this article.
Join Beth Wolf, MD, CPC, CCDS, for an in-depth webcast on the FY2025 spinal fusion MS-DRG updates. Discover key changes in DRG classification, understand impacts on documentation and CMI, and learn strategies to ensure compliance.
Join Angela Comfort, DBA, MBA, RHIA, CDIP, CCS, CCS-P, as she presents effective strategies to strengthen collaboration between CDI, coding, and quality departments in acute care hospitals. Angela will also share guidance on implementing cross-departmental meetings, using shared KPIs, and engaging leadership to foster a culture of collaboration. Attendees will gain actionable tools to optimize documentation accuracy, elevate quality metrics, and drive a unified approach to healthcare goals, ultimately enhancing both patient outcomes and organizational performance.
Optimize your outpatient clinical documentation and gain comprehensive knowledge from foundational practices to advanced technologies, ensuring improved patient care and organizational and financial success. This webcast bundle provides a holistic approach to outpatient CDI, empowering you to implement best practices from the ground up and leverage advanced strategies for superior results. You will gain actionable insights to improve documentation quality, patient care, compliance, and financial outcomes.
Enhancing outpatient clinical documentation is crucial for maintaining accuracy, compliance, and proper reimbursement in today’s complex healthcare environment. This webcast, presented by industry expert Angela Comfort, DBA, RHIA, CDIP, CCS, CCS-P, will provide you with actionable strategies to tackle complex challenges in outpatient documentation. You’ll learn how to craft detailed clinical narratives, utilize advanced EHR features, and implement accurate risk adjustment and HCC coding. The session also covers essential regulatory updates to keep your documentation practices compliant. Join us to gain the tools you need to improve documentation quality, support better patient care, and ensure financial integrity.
Dr. Ronald Hirsch provides critical details on the new Medicare Appeal Process for Status Changes for patients whose status changes during their hospital stay. He also delves into other scenarios of hospital patients receiving custodial care or medically unnecessary services where patient notifications may be needed along with the processes necessary to ensure compliance with state and federal guidance.
Healthcare organizations face complex regulatory requirements under the No Surprises Act and Price Transparency rules. These policies mandate extensive fee disclosures across settings, and confusion is widespread—many hospitals remain unaware they must post every contracted rate. Non-compliance could lead to costly penalties, financial loss, and legal risks. Join David M. Glaser Esq. as he shows you how to navigate these regulations effectively.
Protect your facility from unwanted audits! Join Becky Jacobsen, BSN, RN, MBS, CCS-P, CPC, CPEDC, CBCS, CEMC, and take a deep dive into both the CMS and AMA guidelines for reporting post operative pain blocks. You’ll learn how to determine if the nerve block is separately codable with real life examples for better understanding. Becky will also cover how to evaluate whether documentation supports medical necessity, offer recommendations for stronger documentation practices, and provide guidance on educating providers about documentation requirements. She’ll include a discussion of appropriate modifier and diagnosis coding assignment so that you can be confident that your billing of post operative pain blocks is fully supported and compliant.
During this RACmonitor webcast Dr. Ronald Hirsch spotlights the areas of the OIG’s Work Plan and the findings of their most recent audits that impact utilization review, case management, and audit staff. He also provides his common-sense interpretation of the prevailing regulations related to those target issues. You’ll walk away better equipped with strategies to put in place immediately to reduce your risk of paybacks, increased scrutiny, and criminal penalties.
Copyright © 2024 RACmonitor. Powered by MedLearn Media.
Happy National Doctor’s Day! Learn how to get a complimentary webcast on ‘Decoding Social Admissions’ as a token of our heartfelt appreciation! Click here to learn more →
CYBER WEEK IS HERE! Don’t miss your chance to get 20% off now until Dec. 2 with code CYBER24
