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Payer Advocacy in Action

February 2012

UnitedHealthcare Settlement Checks Slated to Arrive Soon

Physicians who filed claim forms by the deadline as part of the UnitedHealth Group Usual, Customary and Reasonable (UCR) settlement are scheduled to receive funds from the settlement in the coming months. The court-approved settlement fund of $250 million will be paid to physicians, patients and other health care professionals. It is expected that providers who filed claims are expected to receive nearly $200 million from the settlement fund. Physicians who filed claims and have moved since filing should provide their updated mailing address as soon as possible to ensure the delivery of their checks. Contact the Claims Administrator (contact information below), if you filed directly, or the Managed Care Advisory Group (MCAG), if you filed through MCAG (contact information below).

Claims sent direct to Claims Administrator: Most physicians will receive checks from Berdon Claims, LLC in the next couple of months, but if you have not received your check by April 15 and filed a claim directly to the Claims Administrator, contact Berdon Claims, LLC, by:

Claims sent through the Managed Care Advisory Group (MCAG): Most physicians will receive checks from the Managed Care Advisory Group (MCAG) in the next couple of months, but if you have not received your check by April 15and filed through MCAG, you should contact MCAG to inquire about the status of your settlement check by:

Although it is too late to file a claim for damages from this settlement fund, ACC members experiencing out-of-network issues with payers are encouraged to contact ACC’s Payer Advocacy team at (800) 435-9203. In addition, the American Medical Association has an Out-of-Network toolkitExternal Link, which contains detailed information that physician practices can use in their non-contracted dealings with payers. To learn more about what the industry is doing to address out-of-network reimbursement, visit the FAIR Health, Inc. websiteExternal Link, a non-profit entity created under the settlement to help ensure fairness and transparency in out-of-network reimbursement.

Bumbled bundling?

The ACC is investigating complaints regarding numerous health plans incorrectly bundling the reimbursement for interpreting echoes into the inpatient E&M procedure codes based on claims management software developed by McKesson. The ACC, along with the American Society of Echocardiography and American Medical Association, has sent letters of opposition to McKesson and several health plans including Aetna, BCBS of Texas and Horizon, BCBS of New Jersey. McKesson and Aetna responded that they agree both services should be separately reimbursed when the services meet CPT reporting standards. However, payers report that medical record reviews have routinely seen physicians bill both services without completing the documentation requirements, namely the separate written report for the echo interpretation. McKesson and Aetna have concluded that when the reporting standards are met, the use of a modifier -25 (significantly, separate identifiable E&M service) or a modifier -59 (distant procedural service) will be recognized. For the full reporting standards, consult the ACC/AMA CPT Reference Guide for Cardiovascular Coding. Your ACC reminds members to fully and completely document services rendered in the patient's charts for accurate claims submission.

UnitedHealthcare Extends Submission Timeline

Following complaints from the ACC, as well as numerous cardiovascular practices, UnitedHealthcare (UHC) has extended the timeframe to submit Retrospective Notification for the Cardiology Notification Program from 14 to 30 calendar days. The extension means diagnostic cardiac catheterizations and electrophysiology (EP) implant procedures performed on an emergent basis, or during the course of an inpatient stay, must now be submitted within 30 calendar days of the date of service. As a reminder, the UHC Cardiology Notification Program requires ALL diagnostic cardiac catheterizations and EP implant procedures to be pre-notified regardless of setting. Also, the program currently only includes diagnostic cardiac catheterizations and EP implant procedures (pacemakers and ICDs). Notifications for cardiovascular imaging tests such nuclear cardiology, cardiac computed tomography, and cardiac magnetic resonance are separate and listed under the UHC Radiology Notification Program. For more program details, visit the UHC Cardiology Notification Program websiteExternal Link. Feel free to contact ACC Advocacy at 800.253.4636 with feedback on this program.