As the level of emergency department visits
increases in severity,
ED spend is becoming an increasing burden
for health plans.
Data shows that low acuity codes are declining,
while high acuity codes are rising,
and up to 30 percent of insured ED visits
are deemed non emergent.
These trends are likely to continue,
and without an automated review solution,
auditing ED claims can be a challenge.
Optum Emergency Department Claim Analyzer Facility
provides an automated and consistent 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.
Our methodology follows CMS guidelines
by helping ensure the submitted visit level
follows evaluation and management code descriptors.
Here's how it works.
First, standard costs are weighted
based on the ICD-10 reason for visit.
Second, extended costs are weighted
based on the intensity of the service's 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.
Finally, the analyzer calculates the three weights
and recommends the appropriate visit level.
Claims are not denied, but paid at the appropriate level.
Less than 3 percent of repriced claims are appealed,
and annual savings average $3 to $6 per member, per year
for commercial health plans,
$5 to $9 PMPY for Medicare,
and $3 to $6 for Medicaid.
Learn how we can help you improve your ED coding accuracy
and increase your savings today,
with Optum EDC Analyzer Facility.