We are finding more and more commercial payers creating their own Facility ED E/M criteria thus auditing with it  and downgrading our ED levels.  How are you combating this auditing method when the payer is not using the facility E/M grid?   


  • First question- are they providing you the criteria they use? If not, demand it. 

    Second question- are you contracted with them? if so, does your contract address this? 

    As most know, there are no standard guidelines for facility coding of ED visits. In fact Medicare specifically tells facilities to develop their own. I wrote about this issue here:

  • We have tried your first option - and demanded it  but they pushed back and also yes we provided all the CMS guidance currently allowing hospitals to create their E/M grid with the 11 principals. 

    Unfortunately our contracting department signed a blank check (basically signing the contract you adhere to the reimbursement policies)

    Thank you for the info.

  • edited April 2019
    What if these are Medicare Advantage plans and your contract states that they go by CMS guidelines within the contract? Also as you stated Medicare specifically tells facilities to develop their own, so if they go by Medicare guidelines the facility should be the one who mandates what guideline/criteria not the payer, correct?
  • This is rampant throughout the country. The worst offender is a large organization that "U" might know. They are  automatically downgrading and no amount of appeal will make a difference. They have a proprietary program that assigns codes. There is no solution until CMS develops actual coding guidelines, as recommended by MedPAC at the March meeting. But will you stay in business until 2021 to see those guidelines adopted???
  • However if they state they go by Medicare guidelines and Medicare states the facility chooses the program/criteria for e/m level then aren't the Medicare Advantage payer going against current mandate that medicare is going by even though  Medicare hasn't developed any guidelines yet?
  • Yep, but when we talk to CMS about MA plans that state "We follow Medicare guidelines" and then don't follow them, sometimes blatantly, CMS' response is- if you are contracted with them, then we don't care what happens. If you are not contracted and they disregard CMS regulations, we want to know about it.
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