UnitedHealthcare set to deny up to 10% of emergency department claims for being nonemergent
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