Quick update on the letter below...

UHC tweeted out yesterday morning the following:



Speaking off-the-record with our contact at UHC, she said it's a temporary setback, largely due to pressure from the AHA, but the new ED denials policy will absolutely go into effect after CMS lifts the covid national emergency period, declared on March 13, 2020.

This gives our clients time to review their ED outpatient case mix indices versus local market peers to determine if they're at risk of having ED claims denied.

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June 11, 2021

Dear Colleagues,

Starting July 1, 2021, UnitedHealthcare (UHC) will take a new approach to assess emergency department (ED) claims.  The new policy is expected to deny 10% of ED claims:



 

Exactly how will UHC determine which ED claims will be denied? 

A key factor will be the analysis of a hospital’s intensity of services performed, compared to other hospitals for the same CPT code.  Hospital Pricing Specialists has a patent-pending Outpatient Case Mix Index® that is calculated for every acute hospital by ED visit level and primary outpatient surgery.  Our Outpatient Case Mix® Indices are updated annually on a dataset of over 140 million outpatient claims.

Below is a real example of 2 hospitals that perform CPT 99283 – ED Visit with Moderate Severity, and how their Outpatient Case Mix® Indices are different based on their mix and utilization of services.


Example 1 - Hospital with High Outpatient Case Mix® for CPT 99283
 

 


Example 2 - Hospital with Low Outpatient Case Mix® for CPT 99283


 
Note:  Outpatient Case Mix Index® is a registered trademark of Hospital Pricing Specialists LLC

If you'd like more information on our proprietary Outpatient Case Mix® database, feel free to schedule a time to talk on my private calendar:  go.oncehub.com/ricklouie   


Regards,