WEBVTT

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As the level
of emergency department visits

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increases in severity,

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ED spend is becoming
an increasing burden

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for health plans.

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Data shows that
low acuity codes are declining,

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while high acuity codes are rising,

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and up to 30 percent
of insured ED visits

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are deemed non emergent.

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These trends are likely to continue,

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and without
an automated review solution,

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auditing ED claims
can be a challenge.

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Optum Emergency Department
Claim Analyzer Facility

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provides an automated
and consistent process

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to determine
the appropriate visit level.

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As claims enter the system,

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visit level codes
are analyzed for accuracy,

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by reviewing diagnoses
and services performed.

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Our methodology
follows CMS guidelines

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by helping ensure
the submitted visit level

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follows evaluation
and management code descriptors.

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Here's how it works.

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First, standard costs are weighted

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based on the ICD-10 reason for visit.

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Second, extended costs are weighted

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based on the intensity
of the service's workup,

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as measured by
the diagnostic CPT codes.

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Third, patient
complexity costs are weighted

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based on the types
of services typically provided

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for complicating conditions,
defined in the principal,

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secondary, and external cause
of injury codes.

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Finally, the analyzer
calculates the three weights

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and recommends
the appropriate visit level.

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Claims are not denied,
but paid at the appropriate level.

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Less than 3 percent
of repriced claims are appealed,

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and annual savings average
$3 to $6 per member, per year

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for commercial health plans,

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$5 to $9 PMPY for Medicare,

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and $3 to $6 for Medicaid.

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Learn how we can help you
improve your ED coding accuracy

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and increase your savings today,

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with Optum EDC Analyzer Facility.