United Healthcare (UHC) recently announced that beginning April 1, 2020 they will screen all Level 5 evaluation and management code 99285 emergency department claims for possible downcoding or denial using the Optum Evaluation and Management Professional (E&M Pro) tool. The E&M Pro uses patient age and diagnosis to consider either automatically downgrading the claim to a lower level, or to deny the claim altogether.
“ACOEP stands in firm opposition to this practice,” says ACOEP President Robert Suter, DO, MHA, FACOEP-D. “This action will undermine patient access to emergency care and exacerbate the problem of surprise billing. The complexity and volume of our patients continues to increase and they expect us to have the staff and resources to take the best possible care of them. Insurance company tactics like this one devalue the life-saving work done by our members and, by reducing resources, these moves will make it less available to all.”