UnitedHealthcare’s ED Algorithm: How We Reversed $220k in Downgraded Claims

The Problem

UnitedHealth’s algorithm auto-downgrades ED facility fees (CPT 99283-99285) to “non-emergent” (CPT 99281), denying 62% of Level 3-5 claims (KFF, 2023).

The Fix

1. Appeal with Clinical Notes: Highlight keywords like “chest pain” or “shortness of breath.”
2. OIG Reporting: Flag systematic violations to CMS.
3. Peer-to-Peer Escalation: Demand MD-to-MD reviews.

Case Study

Clinic: Orlando Health ED

Issue: $220k in wrongful downgrades.

Result: 85% recovery via OIG complaints + appeals.

CTA

?? Free ED Denial Audit: Send us your last 10 ED claims.

?? https://calendly.com/oscar-medbillingrcm/45min

Next Edition Teaser

?? “How a Cardiology Clinic Slashed Denials by 43% Using AI.”