Optum Denials for E/M and Stroboscopy

QUESTION

I have started to receive a tremendous amount of denials for OPTUM patients that I see and perform a stroboscopy on the same day.??

The letters from the company denies my E/M and pays for stroboscopy and says that the E/M falls under the global?period for the procedure. Interestingly the global period for stroboscopy is 0 days.??

Anyone else seeing this or anyone from the academy working on this?

ANSWER

The challenge of denied claims for stroboscopy procedures by Optum Insurance is indeed frustrating but not insurmountable. Beating Optum begins with an in-depth understanding of the underlying causes of these denials.

AI SYSTEMS ARE BLOCKING PAYMENTS AND DENYING CARE

Unfortunately, our notes, aimed at justifying medical necessity, are increasingly subjected to brief software analyses. In this case these denials were likely generated in 1-2 seconds, underscoring a significant shift in the insurance claims review process. It is now primarily software driven. Many insurance companies have found this tactic to be very successful.?

THIS IS A PROFIT TAKING SOLUTION FOR HEALTH INSURERS

For instance, UnitedHealthcare Group has seen a substantial rise in revenue per insured over the past five years, ending in 2023 ($8,500 per insured grew to $13,700 per insured). They deployed an AI called "nH Predict"? with algorithms fully in place by 2020, suggesting that the use of automated claim denials might be strategically employed to enhance profitability at the expense of patient care.?

Given that Optum is a subsidiary of UnitedHealthcare Group, it is evident that these algorithms are likely being used to obstruct payments for stroboscopy.

AI USE AS THE PRIMARY SYSTEM FOR DENYING CARE AND PAYMENTS IS UNETHICAL

BEFORE your first consultation with these patients, many companies analyze data from EHRs certified for meaningful use to pre-determine the necessity of procedures based on historical claims, often resulting in pre-emptive denials AFTER you see them. As practicing surgeons, we understand the needs of our patients better than AI and predictive algorithms and we must ensure our services are reimbursed as per our contractual agreements.

THE MOST COST EFFECTIVE AN EASY SOLUTION FOR SURGEONS: USE AN AI DESIGNED TO MITIGATE INSURANCE DENIALS

In the current landscape dominated by AI, enhancing the quality of our billing documentation is crucial to this goal. This not only supports our clinical decisions but also aligns better with the AI systems employed by insurance providers.

To counteract these denials, your immediate recourse is to appeal, utilizing strategies that have been proven to enhance the likelihood of successful reimbursement. While Revenue Cycle Management (RCM) services are an option, costing approximately $25-$50 per appeal, they may not be cost-effective for lower-reimbursed procedures and they typically require extended review periods to yield results. Conversely, AI-based mitigation strategies offer a more efficient and scalable alternative, costing significantly less and providing a viable solution for surgeons facing pre-authorization and payment denial issues.

I hope this insight proves beneficial and aids in navigating these challenges more effectively.

Fire up!