UnitedHealth Group plans more scrutiny of ED claims
UnitedHealth Group is looking to cut down on expensive emergency department (ED) claims under a new policy that took effect March 1, Modern Healthcare reported.
The payer will review ED claims with the most serious conditions (Level 4 or Level 5) evaluation and management codes in commercial and Medicare Advantage (MA) plans.
If UnitedHealth finds incorrect claims for the ED visits, it will reduce or deny the claim depending on the contract.
Initially announced in the UnitedHealthcare Network Bulletin in December 2017, the payer said the policy change is part of its “continued efforts to reinforce accurate coding practices.” UnitedHealth said the change is also associated with improving healthcare services, health outcomes and overall cost of care.
To implement the policies, the payer will use the Optum Emergency Department Claim (EDC) Analyzer tool. The tool “determines appropriate E/M coding levels based on data such as the patient’s presenting problem, diagnostic services performed during the visit and associated patient co-morbidities,” according to the December bulletin.
The payer said criteria that may exclude outpatient facility claims from the new policies include:
- Admissions from the ED.
- Critical care patients.
- Patients younger than 2.
- Claims with certain diagnoses that when treated in the ED most often necessitate greater than average resource use, such as significant nursing time.
- Patients who die in the ED.
- Claims from facilities whose billing of level 4 and 5 E/M codes don’t abnormally deviate from the EDC Analyzer tool determination.
UnitedHealth is not the first major payer to take a closer look at ED visits. Last year, Anthem announced a controversial policy to stop paying visits it later deemed medically unnecessary.
Similar to Anthem’s policy, which denied ED coverage for unnecessary visits, UnitedHealth, the nation’s largest payer, is looking to lower ED costs. There is a major difference, though. While Anthem’s policy looks to move patients away from EDs to less expensive locations like urgent care centers and retail clinics, UnitedHealth’s change is about making sure hospitals are billing properly.
Backing up the payer on this added focus is a 2017 study in Colorado that found hospitals are increasingly billing at Level 5 levels. The Colorado Center for Improving Value in Health Care report found that Level 5 codes for ED visits increased to one-third of commercial claims in Colorado compared to less than one-quarter in 2011. The other levels all decreased.
So far, there hasn't been swift criticism of the UnitedHealth policy change. Anthem's decision last year brought almost immediate opposition from physician groups and hospitals. The American College of Emergency Physicians and its Missouri chapter called Anthem's ED policy a “clear violation of the national prudent layperson standard.”
Also, Atlanta-based Piedmont Hospital and five sister facilities sued Anthem and its subsidiary Blue Cross Blue Shield of Georgia because of both the ED policy and its decision to stop paying for imaging in hospitals. The hospitals charged that the payer is involved in “a national scheme” geared to “intentionally deteriorate coverage for policyholders.”
- Modern Healthcare UnitedHealth tightens reins on emergency department reimbursement
- Healthcare Dive Healthcare leaders challenging Anthem's ED policy in Missouri