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UHC Policy on ER Claims

Some Possibly Expensive Changes to How United Healthcare Processes ER Visit Claims

March 21st, 2018

New UHC Policy on ER Claims

Recently Anthem BCBS informed all of their policyholders that they were making a change to how they were going to process claims for Emergency Room (ER) Visits.  For those members that visit the ER with minor issues, this was possibly not very good news.  Well now it seems that United Healthcare (UHC) is going to follow a similar, but not equal, path as their competitor and they too have announced some changes as to how they are going to evaluate and process ER visit claims for many of their 49 million members.

As you know Premier Employer Services, a Denver PEO, utilizes United HealthCare as our preferred Health Insurance carrier for employee benefits and many of our employees are on a UHC plan administered by Premier.  This new change should not affect many of our employees, however, we want everyone to be aware of the policy change in case you may have missed the March 1, 2018, announcement.

As of March 1st UHC has announced that they are going to re-evaluate claims filed by hospitals for some of the most expensive ER visits.  The intent is to address “inconsistencies in coding accuracy” that originate from the hospitals for intensive level 4 and 5 services.  This policy change will also apply to stand-alone emergency rooms.  UHC is going to begin using a new process tool that they are calling an “emergency department claim analyzer tool” that will help them determine what the appropriate coding should be “based on data such as a patient’s presenting problem, diagnostic services performed during the visit and associated patient co-morbidities.”

If a hospital has miscoded a procedure they may see claims reduced or even denied for procedures that they have submitted with incorrect coding.

The intent was to address “inconsistencies in coding accuracy” by hospitals for the intensive level 4 and level 5 services. The policy also applies to freestanding emergency rooms.

UnitedHealthcare will be using an “emergency department claim analyzer tool” that will determine the appropriate coding “based on data such as a patient’s presenting problem, diagnostic services performed during the visit and associated patient co-morbidities,” according to a December bulletin sent to hospitals.

The bottom line is that this could result in the hospitals passing on some, or all, of the portions that were denied in the claim to the patient.  Copays and premiums will not be impacted by this change but patients could see a large bill in the mail if the hospitals attempt to get paid by UHC and they have miscoded the procedures that were done.  UHC is trying to contain rising ER visit costs by attempting to change hospitals behavior in calms submission.  While this is being done for a very good reason it can still negatively impact some of our employees.  Be sure you are aware of this policy change before you head into the ER and consider using an Urgent Care facility for many of your less critical health needs to avoid possible additional costs.

See this article from the Naples Daily News for a more detailed explanation of potential impact form this policy change and be sure to call us if you have any questions or concerns regarding your UHC policy coverage.