UnitedHealthcare Redesigns Emergency Department Reimbursement Policy
March 2018 ~
UnitedHealthcare (UHC) has announced plans to introduce a new payment policy intended to reduce its emergency department (ED) claims cost.
According to the announcement, the insurer will make revisions to its current ED Facility Evaluation and Management (E/M) Coding Reimbursement Policy for UHC Commercial Plans and will adopt new policies for UHC Medicare Advantage (MA) plans, as well as UHC Community Plans in select states. UHC states these enhancements align with its commitment to the Triple Aim of improving health care services, health outcomes, as well as overall cost of care and focus on facility ED claims that are submitted with level 4 (99284, G0383) and level 5 (99285, G0384) E/M codes.
Effective March 1, 2018, these policies will apply to all facilities, including freestanding facilities, that submit ED claims with level 4 and 5 E/M codes for members of the affected plans, regardless of whether they’re under contract to participate in UHC’s network.
UHC states facilities submitting claims for ED E/M codes may experience adjustments to level 4 or 5 E/M codes to reflect an appropriate level E/M code or may receive a denial, based on the reimbursement structure within their agreements with UHC. Facilities submitting claims for ED E/M codes may experience adjustments to level 4 or 5 E/M codes to reflect an appropriate level E/M code or may receive a denial, based on the reimbursement structure within their agreements with UHC.
Facilities will be given the opportunity to submit reconsideration or appeal requests if it is believed a higher level E/M code is justified (in accordance with the terms of their contract and/or Administrative Guide).
As part of the implementation of these policies, UHC will use the Optum Emergency Department Claim (EDC) Analyzer tool to determine 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.
UHC states criteria that could potentially exclude outpatient facility claims from these policies include, but are not limited to, the following:
- Admissions from the emergency department
- Critical care patients
- The patient is less than 2 years old
- Claims with certain diagnosis that when treated in the ED most often necessitate greater than average resource usage, such as significant nursing time
- Patients who have expired in the emergency department
- Claims from facilities whose billing of level 4 and 5 E/M codes does not abnormally deviate from the EDC Analyzer tool determination.
Source(s): Modern Healthcare; Becker’s Hospital Review; Healthcare DIVE; UnitedHealthcare Network Bulletin;