UnitedHealth may start rejecting complex ER claims

A lighted emergency room sign outside of a hospital
United Health has adopted a new policy for emergency services as of March 1 that focuses on level-four and level-five evaluation and management codes. (Getty/MJFelt)

Despite the controversy and pushback already generated by insurance giant Anthem’s decision to more closely evaluate emergency department claim submissions, another big payer has made similar moves.

Minnesota-based UnitedHealth quietly announced in a bulletin (PDF) late last year that it was adopting a new policy for emergency services as of March 1. It described the new policy as including enhancements that “support UnitedHealthcare’s commitment to the Triple Aim of improving healthcare services, health outcomes, and overall cost of care.”

The revised policy focuses on level-four and level-five evaluation and management codes. The intensity of emergency services are rated on a five-point scale, with their complexity climbing with the number. Level-five claims involve patients with the most complex and usually most expensive to treat conditions.

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If UnitedHealth decides a coding is not justified, it could downcode provider reimbursement or reject it completely. The provider would have the opportunity to appeal either a downcode or denial. Any claims with four specific codes will be put through UnitedHealth’s proprietary data analytics software. The bulletin stated the organization “determines 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.”

RELATED: Anthem alters controversial ER coverage policies

The change is likely to lead to lower reimbursements for hospitals that treat patients in the emergency department. However, the bulletin does not suggest that patients would be on the hook for charges, as with the Anthem policy.

Anthem announced its policy last summer, with the intent of discouraging its enrollees from using hospital emergency departments for care that could be delivered at another facility, such as one that specializes in urgent care, or even a doctor’s office. But the insurer drew fire for the policy, with providers complaining it forced patients who may be in severe pain or distress to self-diagnose.

Anthem has since modified some components of the policy, including adopting a stance of always paying a claim if a patient was admitted as an inpatient, was being treated as an existing outpatient, or when the patient received surgery, a CT scan or an MRI.

UnitedHealth has also imposed similar exceptions to the rule, including patients who wind up being admitted to the hospital, patients who receive critical care services, patients who are two years old or younger or patients who died in the emergency department.

RELATED: Providers warn Anthem’s ER policy may violate federal law