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Emergency Department Analyzers

Control rising emergency outpatient facility and outpatient professional costs with automated, consistent and defensible E/M coding evaluation.

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Claims Coding Transcript

WE UNDERSTAND EMERGENCY DEPARTMENT SPEND IS AN INCREASING BURDEN FOR HEALTH PLANS AS THE LEVEL OF E.D. VISITS IS INCREASING IN SEVERITY. 

OUR DATA SHOW THAT LOW ACUITY CODES ARE DECLINING WHILE HIGH ACUITY CODES ARE RISING. AND UP TO 30% OF INSURED E.D. VISITS ARE DEEMED NON-EMERGENT. THESE TRENDS ARE PROJECTED TO CONTINUE, AND WITHOUT AN AUTOMATED REVIEW SOLUTION, AUDITING ED CLAIMS CAN BE A CHALLENGE.

OUR E.D. CLAIMS CODING SOLUTION PROVIDES AN AUTOMATED, CONSISTENT, AND DEFENSIBLE PROCESS TO DETERMINE THE APPROPRIATE VISIT LEVEL.  AS CLAIMS ENTER THE SYSTEM, VISIT-LEVEL CODES ARE ANALYZED FOR ACCURACY BY REVIEWING DIAGNOSES AND SERVICES PERFORMED. THE METHODOLOGY FOLLOWS CMS GUIDELINES BY HELPING ENSURE SUBMITTED VISIT LEVEL FOLLOWS EVALUATION AND MANAGEMENT CODE DESCRIPTORS.

FIRST, STANDARD COSTS ARE WEIGHTED BASED ON THE ICD-10 REASON FOR VISIT.

SECOND, EXTENDED COSTS ARE WEIGHTED BASED ON THE INTENSITY OF THE SERVICES WORKUP AS MEASURED BY THE DIAGNOSTIC CPT CODES.

THIRD, PATIENT COMPLEXITY COSTS ARE WEIGHTED BASED ON THE TYPES OF SERVICES TYPICALLY PROVIDED FOR COMPLICATING CONDITIONS DEFINED IN THE PRINCIPAL, SECONDARY AND EXTERNAL CAUSE OF INJURY CODES.

THE SYSTEM THEN CALCULATES THE THREE WEIGHTS AND RECOMMENDS THE APPROPRIATE ED VISIT LEVEL.

CLAIMS ARE NOT DENIED BUT PAID AT THE APPROPRIATE LEVEL. LESS THAN 5% OF REPRICED CLAIMS ARE APPEALED.   OUR ANNUAL SAVINGS AVERAGE IS $10 – 12 PMPY FOR COMMERCIAL CLIENTS, $12-14 PMPY FOR MEDICARE CLIENTS AND $8 – 10 PMPY FOR MEDICAID CLIENTS.

IMPROVE YOUR ED CODING ACCURACY AND INCREASE SAVINGS TODAY WITH CLAIMS CODING SOLUTION.

OPTUM IS FOCUSED ON EMPOWERING ACCURATE, EFFORTLESS PAYMENTS FOR ALL BY PROVIDING SOLUTIONS AT EVERY TOUCHPOINT IN THE BILLING AND CLAIM LIFECYCLE.

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Ensure E/M visit level assignment for facility claims

Emergency Department Claims (EDC) Analyzer — Facility: Helps health plans determine fair and consistent levels of facility reimbursement for outpatient emergency department (ED) services. We apply standard cost factors with extended cost factors and patient complexity costs to determine the appropriate visit level.

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Ensure appropriate E/M level assignment for professional claims

E&M Professional Analyzer: Assesses codes in the context of other claim data to ensure medical decision-making associated with the visit reflects the visit-level code description. It allows for automated adjustment of professional claims with accuracy and scalability.

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Identify non-emergent facility claims in the ED setting

Non-Emergent Claims Analyzer: Assesses outpatient ED claims to determine if care could have been provided in a non-emergency setting. It uses the member’s reason for visit, as well as other contributing claim information, to consistently apply prudent layperson guidelines.

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