Insurance providers never want to cover more than they have to, and UnitedHealthcare (UHC) is no different. With a new policy put into effect in March, UHC vowed to crack down on emergency department visits that are coded as Level 4 or Level 5 even when they do not fit the necessary requirements. This process, known us upcoding, can stem from everything from simple carelessness to outright fraud, and UHC promises to tighten restrictions on facilities that report these types of codes in large quantities.
Under this new policy, UHC now reviews all claims that report either Level 4 or Level 5 in order to confirm that these high codes are medically necessary. Anytime a facility submits such a claim, UHC’s software automatically flags and evaluates it based on the documentation.
This update applies to everyone, from members of UHC’s commercial plan to members of its Medicare Advantage plan, and even those submitting claims from non-participating facilities. As of now, there are only a few small exceptions to this rule, including patients younger than two, critical care patients, patients requiring above-average use of resources, and patients who die while in the emergency department.
For those who disagree with UHC’s final decision, there is, as always, the option to appeal the claim. Given that the claims, which are often long and complex, are sorted entirely by a computer program, it is more than likely that UHC will make mistakes and some claims will need to be appealed.
If you work for a facility that codes high numbers of Level 4 and Level 5 codes, be sure to take extra care in reviewing your claims before you submit them. Double-checking your information before you submit it is always a good idea, and in this case, it may even save you from a long and costly audit.