UnitedHealth takes aim at costly ED visits with new policy: 5 things to know

UnitedHealth Group's insurance arm, UnitedHealthcare, changed its emergency department reimbursement policy for commercial and Medicare Advantage plans.

Here are five things to know about the policy, according to a December 2017 bulletin.

1. Effective March 1 nationwide, UnitedHealthcare will review and possibly adjust or deny facility ED claims submitted with level 4 and level 5 evaluation and management codes, with facilities able to submit reconsideration or appeal requests. Levels are based on patient interventions, with level 4 and 5 codes dictating the most costly and intensive ED care. Blunt and/or penetrating trauma, severe infections and chest pain are some examples, according to the American College of Emergency Physicians.

2. A UnitedHealthcare spokesperson told Becker's Hospital Review, "Promoting accurate coding of healthcare services is an important step in achieving the Triple Aim of better care, better health and lower overall costs." The policy change applies to all facilities and freestanding EDs submitting level 4 and 5 codes for UnitedHealthcare members, regardless of in-network status.

3. UnitedHealthcare will use the Optum ED Claim Analyzer tool to determine appropriate evaluation and management coding levels. Data such as diagnostic testing, comorbidities and the patient's presenting problem will be considered by the tool.

4. In the December 2017 bulletin, UnitedHealthcare said the policies were developed to "address inconsistencies in coding accuracy and were based on the [evaluation/management] coding principles created by the Centers for Medicare & Medicaid Services that require hospital ED facility E/M coding guidelines to follow the intent of [Current Procedural Terminology] code descriptions and reasonably relate to hospitals' resource use."

5. UnitedHealthcare listed several exceptions to the policy in its bulletin, including claims for: 

  • admissions from the ED
  • critical care patients
  • patients less than 2 years old
  • certain diagnoses requiring greater than average resource use when performed in the ED
  • patients who die in the ED
  • facilities whose billing of level 4 and 5 E/M codes does not abnormally deviate from Optum's EDC Analyzer tool determination

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