UHC moves from denial to downcoding of E/M claims

UnitedHealthcare (UHC) is changing how it handles claims for evaluation and management (E/M) services when the medical record documentation does not support the E/M level submitted. Currently, UHC denies such claims, in which case the physician must either appeal, resubmit the claim with the appropriate level of service, or amend the documentation to support the level of service billed.

Under a policy change effective in the second quarter of 2019(www.uhcprovider.com), UHC will no longer automatically deny a claim based on the documentation but instead may adjust the level of a submitted code to reflect what it believes is appropriate and then pay it. The policy appears aimed at Level 4 and 5 services. If a physician disagrees with the adjustment, he or she could still appeal as that process will not change.

Your billing staff will need to be on their game and know what the appropriate payment is for the E/M codes they submit to catch potential downcoding by UHC. Close review of remittance advices may be in order. Otherwise, your practice risks being underpaid and not knowing it.

– Kent Moore, Senior Strategist for Physician Payment at the American Academy of Family Physicians