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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,

Rick Louie
Managing Director
Hospital Pricing Specialists LLC

LinkedIn Profile:  https://www.linkedin.com/in/ricklouie/

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