UnitedHealth division rising force in combatting hospital claims denials

UnitedHealth is best known for being the 800-pound gorilla of health insurers. But it also operates a sizable business in getting hospitals higher payments from the Medicare program, the New York Times reported.

UnitedHealth's division, known as Executive Health Resources, has shown great skills in building hospital payments, according to the hospital sector. "They're the market leader," Anthony J. Burke, a senior vice president for the American Hospital Association, told the New York Times.

The services provided by such firms gained popularity in the five years since recovery audit contractors (RACs) began bird-dogging claims from hospitals on behalf of the Centers for Medicare & Medicaid Services in an attempt to curb overbilling or unnecessary billing. RACs have clawed back billions of dollars to date, but their collections have slowed in recent quarters due to pushback from hospitals, which has led to a moratorium on auditing specific claims, as well as a delay in awarding new contracts to RACs, among other reasons.

The company uses hundreds of physicians as advisors to help contest claims, particularly involving short hospital stays, chest pains and other issues that are often red flags for  RACs. It steps in primarily when hospitals struggle to justify the claims on their own, according to the New York Times. The company charges $150 to $250 to review a single case.

Executive Health Resources was able to help California's Community Hospital of the Monterey Peninsula collect some $7 million in uncontested claims. But another facility, Singing River Hospital in Mississippi, was unable to get some denied billings overturned.

Moreover, the changes in the two-midnight rule prompt companies in Executive Health Resource's line of business--such as Accretive Health--to bill more short stays as observational care.

To learn more:
- read the New York Times article