High-intensity billing in ERs has increased, but not only due to upcoding

 

• High-intensity billing for emergency services has increased significantly since 2006, according to a recent study.
• The proportion of emergency room visits billed as “high intensity” that don’t result in a hospitalization grew from 4.8% in 2006 to 19.2% in 2019, reflecting not simply increasingly aggressive coding, but the ER’s shifting role in the acute care ecosystem, researchers said.
• Roughly half of the growth in high-intensity billing was expected due to shifts in administrative measures of patient cases and care services available in claims data, along with potentially more serious conditions, such as chest and abdominal pain, making up a greater share of visits.

Researchers used an all-payer national sample of ERs to analyze high-intensity billing in ER visits that don’t result in hospitalizations, called “treat-and-release” ER visits, for the study published in Health Affairs this month.

They found that the increase in high-intensity billing for emergency services reflected an increase in the case mix of patient presentations and the services performed in the ER to manage their care, suggesting that coding practices alone don’t account for the trend.

Clinician billing practices in the ER have come under increased scrutiny in recent years as the amount of high intensity visits has grown.

A 2018 analysis of the Medicare fee-for-service population found the proportion of ER visits associated with high-intensity billing increased from 46% in 2006 to 58% in 2012. By 2017, the median rate of high-intensity billing was 67%.

Worries about fraudulent upcoding are widespread in the healthcare system, especially in Medicare as research suggests fraud could be costing the government billions of dollars a year. Regulators are taking a stronger look at how to tamp down on actions like upcoding amid rising concerns about Medicare’s long-term solvency as America’s population grows older.

More than a fifth of Medicare claims for emergency services across multiple providers don’t have adequate documentation to support the level billed, according to the HHS Office of the Inspector General.

However, “to frame increasing high-intensity billing as a consequence of either changes in patient presentations or changes in billing practices would be to set up a false dichotomy that fails to acknowledge the substantial evolving role of the ED in care delivery,” researchers wrote in the new study.

For example, more primary care physicians are referring patients to the ER for quick diagnostics, and the growth of urgent care clinics provides an alternate setting for low-acuity visits that otherwise might have gone to the ER. In addition, older patients and those with multiple chronic medical conditions account for a growing share of the U.S. population, creating an increasingly complex case mix.

“In addressing potentially inappropriate billing practices, payers must acknowledge the increasing complexity of care for a treat-and-release ED patient population composed of older, more comorbid, and clinically undifferentiated patients, to avoid hospitalization, ensure safe discharge, and improve acute care outcomes,” researchers said.

https://www.healthcaredive.com/news/high-intensity-billing-emergency-room-upcoding/639289/