Plan Makes a Grab for Prior Claims Payments
Many health plans and third party payers have for years been using claims re-coding as a way of reducing plan benefits and payments to physician in order to add to plan profitability. Recently, United HealthCare (UHC) launched an escalation of this practice in an attempt to recoup millions of dollars paid to emergency physicians over several years, and it is about to boil over into a full-scale shooting war.
The practice of down-coding or re-coding of claims involves retrospective review of claims submitted by providers to plans, and then making payment (for contracted claims) or determining a benefit amount (for out-of-network claims) that is based on a different coded level of service or type of procedure than was submitted by the physician, resulting in a lower payment by the plan. As you can imagine, this practice is pretty insulting to the physician, since the plan is basically saying: “Doctor, you are lying about the services you provided to our enrollee in order to obtain a higher payment than you deserve”. It is especially insulting when payers down-code without even bothering to request and read the medical record, or rely just on the final diagnosis rather than the entire chart, or use auditors that have little training in coding to make these determinations. Now I am certainly not the first to acknowledge that some physicians intentionally ‘over-code’ their claims, or ‘scrub’ their medical record documentation to support a higher level of service than was justified by their patient’s condition. I do not believe this is a rampant occurrence, and I have seen enough independent audits of ER claims by coding experts to know that the great majority of ER physician’s claims are coded properly.
In recent demand letters to several ER physician groups and billing offices around the country, UHC claims to have reviewed a handful of ER physician claims with the highest level Evaluation and Management code (Level 5 or CPT 99285), and found that between 97 and 100% of these L5 claims were over-coded. Extrapolating these determinations to all of the thousands of L5 coded claims submitted by these ER groups over several years, UHC is demanding that the groups pay back millions of dollars in ‘inappropriate payments’ to the physicians. To the groups that received these letters, this is like watching torpedoes being dropped into the water at Pearl Harbor, aimed to sink their practice.
So what is behind this renewed effort to recoup these payments? Is it really true that nearly 100% of ER claims are over-coded, and that greed and fraud is rife within the profession of emergency medicine? A recent report by the Office of the Inspector General noted that the percentage of Level 5 coded ER physician claims has risen substantially and consistently over the last several years. Personally, this does not surprise me, for two reasons. This first is that managed care has been working very hard to get patients to use alternative sources of care, like their primary care physician’s office, or an urgent care center, when they don’t really need to go to the ER. Reducing the number of ‘less-sick’ patients in the ER means that over time the average patient in the ER will tend to require more services, and be ‘sicker’, and this in turn makes the percentage of the ER population that meets Level 5 criteria grow. The second reason for this growth in the percentage of L5 claims is that these medical groups have been training their physicians to produce more thorough medical records, and adopting electronic charting and other tools to assist physicians in producing these records. Improved charting in turn support higher, and probably more appropriate, coding of these claims. Of course, the payers would argue that these efforts just promote over-coding.
Auditing a sampling of claims and extrapolating the results to thousands of previously paid claims is nothing new. CMS, through its hired gun Recovery Audit Contractor teams, has used this technique to try to recoup payments in order to deal with its huge budget deficit, and browbeat providers into coding claims more conservatively. Many of the claims that UHC demanded recoupment payments on were Medicare Advantage claims; however, as Mr. Ed Gains pointed out in a recent communication to ACEP, Medicare requires a ‘progressive corrective action’ approach that limits these Med Advantage plans from extrapolating overpayments based on single ‘probe audit’ findings. Perhaps UHC hasn’t read the rules. We don’t even know if UHC used randomly selected claims for these audits. In any case, insisting that 100% of the claims were up-coded…….come on, that’s just pure unadulterated b.s. I don’t really know if UHC is doing the same sort of down-coding and extrapolation recoupment demands on other physician specialists, like cardiologists or gastroenterologists, or general surgeons, but I doubt it. That’s not because other specialists are less likely to succumb to greed than ER physicians: ER physicians provide 4-20 times as much charity care as any other specialist. It’s because if I were a gastroenterologist in UHC’s contracted network of providers, and UHC told me that 100% of the claims with my highest level E&M codes were over-coded, I would tell UHC to go screw itself and resign from the plan, no matter how my practice might be impacted. ER physicians, however, don’t have the right to refuse to treat UHC’s enrollees, because EMTALA mandates that they treat everyone, regardless of insurance status or ability to pay.
It won’t help ER physicians to simply refuse to respond to these UHC letters demanding millions in paybacks, because the plans can simply deduct these payments from future claims to recoup this money. The only option that ER physicians have is to fight back against these audits, and try to prove they are wrong. That won’t be easy, because claims coding is as much art as science, subject to interpretation. CPT coding rules rely on words like ‘high complexity medical decision making’ and ‘moderate severity problem’, and the examples in the CPT coding manual are sparse, and fail to distinguish the thresholds between moderate and severe cases for any particular type of presenting problem. I suspect this will all end up in court, or multiple courts, wasting even more time and money that should be used to care for patients. Why is UHC doing this? Because of EMTALA, there really is no reason not to, unless some perspicacious judges out there decide to rap UHC’s knuckles with a BIG ruler.
