UnitedHealth Consultant Aims to Fix Medicare Reimbursement

UnitedHealth Group, one of the nation's largest insurers, owns a consultant that is fighting to fix what it believes to be flaws in Medicare reimbursement, according to a report in the The New York Times.

The consultant, Executive Health Resources, is often in the middle of hospital payment disputes with Medicare. For example, Executive Health is under contract to review claims for the University of Cincinnati Medical Center. In June, HHS' Office of the Inspector General informed UC Medical Center it must refund the government more than $9.8 million after a federal audit found the medical center overbilled Medicare between 2010 and 2011. The OIG's findings were largely the result of claims the auditors rejected as inpatient stays.

The OIG audited 228 sample claims submitted to Medicare by UC Medical Center from 2010 to 2011. The audit revealed the medical center failed to follow billing requirements for 127 of the audited claims. The failure to follow the requirement resulted in Medicare being incorrectly billed and the medical center receiving $603,267 in overpayments from 2010 to 2011. Based on the sample of claims audited, the OIG projected UC Medical Center overbilled Medicare for more than $9.8 million from 2010 to 2011.

UC Medical Center disagreed with the OIG findings, and Executive Health is aggressively contesting the government's findings by arguing the governments methods are flawed, according to The Times.

Many hospitals employ Executive Health to review claims the hospitals believe qualify as inpatient but have been unable to justify as inpatient using their own methods. Executive Health employs physician advisers to examine stays to determine if they qualify as inpatient. However, the final decision is made by the hospitals, according to the report. 

Although Executive Health is involved in high stakes disputes and uses experts to determine how a stay should be classified for Medicare billing purposes, government auditors sometimes disagree with Executive Health's analysis. For example, in 2012, a government audit found Pascagoula, Miss.-based Singing River Hospital had submitted inappropriate bills for approximately one-third of the 100 claims the auditors reviewed. Even when Singing River Hospital pointed to Executive Health's analysis as justification for its billings, the auditors refused to change their findings.

More Articles on Medicare Reimbursement:

The Cost of Unusual Medicare Physician Billing: 5 Things to Know
Legislation Introduced to Ease Readmission Penalties on Some Hospitals 
House Members Send Letter to CMS Addressing Readmission Penalties