Evaluation and Management services are among the most common types of care provided to patients by physicians. Unfortunately, Payers often struggle with overpayments due to a lack of clarity in HCPCS codes and Modifier usage. Payers are also challenged by billing errors and fraudulent claims. The Centers for Medicare & Medicaid Services (CMS) estimates that 95% of the highest reimbursed E&M claims are due to coding errors.
Upcoding, Downcoding, and Modifier abuse are the most common reasons for E&M services payment errors. These overpayment errors have had a significant impact on both Medicare and Commercial plans and have been the determined result of a lack of education in correct coding, inappropriate modifier usage, and a lack of the resources and know-how required to accurately detect E&M claim overpayments and provider abuse. In addition, recurring overpayments are difficult to detect and prevent. The CMS, emphasizing the need to educate providers on accurate coding and compliance, has launched the National Correct Coding Initiative.
Health plan sponsors are challenged by:
- E&M errors can easily result in recurring overpayments because errors are sometimes caused by improper billing practices
- Typical forms of E&M errors include inappropriate Upcoding/Downcoding, Bundling/Unbundling, and Modifier abuse
- Lack of advanced technology to identify and report on provider billing errors
- Need for a consultative approach to develop a customized solution to address E&M billing practices
- Lack of education on HCPCS coding and appropriate billing practices
- Lack of resources to cross validate all claims with medical reviews to ensure the billing of the correct level of service
SCIOinspire’s E&M service is customized overpayment identification and management program that helps payers design and implement a long term plan to avoid overpayments. The program also quantifies the financial impact of E&M Upcoding and Modifier 25 abuse. Our E&M Service, in which we partner with clients, is consultative in nature and creates a customized strategy to help resolve improper E&M billing practices within provider networks.
SCIOinspire’s E&M program involves close collaboration with payers to explore options and to solidify their goals in the implementation of an E&M program. Based on these mutually defined goals, we will customize an audit program that can include any or all of the following activities:
- Identifying Upcoding and Downcoding based on diagnostic services and billing documents for procedures
- Thorough review of supporting documents and claims to check for improper payments for services that were not documented
- Accurate identification of a wide range of modifier abuse, including Modifier-25
- Claims data analysis to identify and prioritize provider audits
- Provider outreach and education
- Medical record requests and review
- Overpayment calculation & recovery
- In-depth analysis by our domain experts, certified coders/clinicians, pharmacists, and auditors
- Creating a customized, actionable strategy to address improper E&M practices
- SCIOinspire always flags and reports any identified systemic overpayments so our clients can prevent them in the future
Evaluation and Management Program
