UnitedHealthcare tightens reins on emergency department reimbursement

The nation's largest health insurer, UnitedHealth Group, is following rival Anthem's footsteps with a new payment policy aimed at reducing its emergency department claims costs.

UnitedHealthcare will utilize the Optum Emergency Department Claim (EDC) Analyzer to determine the emergency department E/M level to be reimbursed for certain facility claims. The EDC Analyzer applies an algorithm that takes three factors into account in order to determine a Calculated Visit Level for the emergency department E/M services rendered. 

The three factors used in the calculation are as follows:

Presenting problems – as defined by the ICD-10 reason for visit (RFV) diagnosis;

Diagnostic services performed – based on intensity of the diagnostic workup as measured by the diagnostic CPT codes submitted on the claim (i.e. Lab, X-ray, EKG/RT/Other Diagnostic, CT/MRI/Ultrasound); and

Patient complexity and co-morbidity – based on complicating conditions or circumstances as defined by the ICD-10 principal, secondary, and external cause of injury diagnosis codes.

Facilities may experience adjustments to the level 4 or 5 E/M codes submitted to reflect a lower E/M code calculated by the EDC Analyzer or may receive a denial for the code level submitted. For certain facilities who experience adjustments to a level 4 or 5 E/M code, we may estimate reimbursement for the adjusted code based on historical claims experience, and in such event the facility may resubmit an adjusted claim which we will adjudicate based on the new charges submitted in accordance with this policy.

Criteria that may exclude Facility claims from being subject to an adjustment or denial include:

? The patient is admitted to inpatient or observation, has an outpatient surgery during the course of the same ED visit, or is discharged/transferred to other types of health care institutions;

? Critical care patients (99291, 99292);

? 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; or

? Claims from facilities billing level 4 and 5 E/M codes that do not disparately deviate from the EDC Analyzer.