UnitedHealthcare Eliminates Consult Codes as a Reimbursable Service

UnitedHealthcare (UHC) is joining the ranks of those carriers that no longer cover consult codes (99241-99245 and 99251-99255), effective Oct. 1, 2017. This notification was released in UnitedHealth’s June 2017 bulletin in which it noted its commitment to ensure that there will be multiple communications to clarify this change. UHC will follow the Centers for Medicare & Medicaid Services’ (CMS’s) role in crosswalking these codes to the appropriate office visit, form of hospital care, nursing facility, home service, or domiciliary/rest home care in lieu of the consult service.

Why now? Medicare changed its policy on consult codes in 2010, and for seven years UHC has continued to pay for these services, but suddenly they have had a change in policy. UHC claims that once CMS made its policy change, they began data analysis to gain a better understanding of the “misuse” of the consultation services codes for the patient population – but it seems hard to imagine that they were not already data-mining this information, knowing that carriers data-mine just about every element of healthcare.

In the UHC bulletin, it is noted that this change in strategy is being made due to their “commitment to the triple aim of improving healthcare services.”

So, what is the triple aim? “Better care, better health, and lower costs,” according to the UHC website. It is their call to action to transform their entire product, network, and clinical strategy to achieve these goals. So, if elimination of reimbursement for consult codes is part of the triple aim, which element is it impacting? Better care? No. Better health? No. Lower costs? By cutting physician reimbursements by not allowing consult codes, they will save money, and thereby lower their own personal costs. Look, making a dollar is the American way, and there is nothing wrong with it, as long as we:

  • First, call it what it is. UHC is not making healthcare or treatment for the insured better by eliminating consult codes; they are lining their pockets.
  • Second, allow physicians and providers all across the country to work to better their own profit margins without being shamed for profiting in the business of medicine.

Let’s start by comparing profit margins of UHC to that of the average profit margin of a physician organization, and then let’s talk about where we could lower costs in other areas. A news release on UHC’s website shows a 2017 financial outlook projecting revenues of $197 to $199 BILLION. It appears the triple aim is working well for UHC.

So now I turn my focus to the average coder/auditor/biller in a physician practice/organization. Many need to really look at facts such as these and really consider your job and its purpose. When CMS changed the rules back in 2010 and even with recent comments regarding this change, we have heard some welcome it, indicating that consults were too confusing and asserting that this will eliminate ambiguity. Actually, what this does is eliminate an option a provider has to be more adequately reimbursed for the work of a consult. A consult is an encounter in which a provider sees a patient at the request for an opinion about the patient’s condition from another provider. So, if the originating provider really doesn’t need the opinion, it would not be a consult.

So for example, say an ER physician sees a patient and sends the patient to an orthopedist for evaluation and treatment – does the ER physician need the ortho’s opinion? No, so it is not a consult; so the rules really are pretty easy, once explained properly. Therefore, our physicians and providers will now be required to see patients, render an opinion, and report this back to the originating provider without additional reimbursement for the additional work. I’m sorry, but I’m still missing how according to UHC, this will lower costs to the overall healthcare system, as it actually is still work that is required but now has no financial reward for the provider.

We also heard multiple remarks from individuals not knowing that UHC once did cover consult codes. What a huge loss of reimbursement for these organizations. Take the time now, within your organization, and identify your top 10 payers, then perform your own data mining and identify each that will still cover consult codes – and bill them. This is reimbursement that your organization is owed, it is within the rules, and completely allowed. Do not encourage the use of elimination of consult codes across the board in your practice just to make it easy and less confusing as it pertains to who will pay and who won’t.

 This reimbursement is available on the table and may not be for much longer, as other carriers will probably follow suit. And be sure to continue to bill UHC for consults until Oct. 1, 2017.

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Shannon DeConda CPC, CPC-I, CEMC, CMSCS, CPMA®

Shannon DeConda is the founder and president of the National Alliance of Medical Auditing Specialists (NAMAS) as well as the president of coding and billing services and a partner at DoctorsManagement, LLC. Ms. DeConda has more than 16 years of experience as a multi-specialty auditor and coder. She has helped coders, medical chart auditors, and medical practices optimize business processes and maximize reimbursement by identifying lost revenue. Since founding NAMAS in 2007, Ms. DeConda has developed the NAMAS CPMA® Certification Training, written the NAMAS CPMA® Study Guide, and launched a wide variety of educational products and web-based educational tools to help coders, auditors, and medical providers improve their efficiencies. Shannon is a member of the RACmonitor editorial board and is a popular guest on Monitor Mondays.

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