Managed Care Outlook 2025

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Read time: 5 minutes

Three areas where intensive focus on payor fraud, waste and abuse detection and prevention efforts will pay significant dividends in 2025 involve reimbursement for emergency department facility services, molecular panels and remote neuromonitoring.

Emergency services

Emergency service disputes will again be a focal point for fraud, waste and abuse investigations, with a particular focus on facility (hospital/freestanding emergency room (ER)) upcoding of evaluation and management (E/M) charges and challenges to payor policies on the handling of high-level E/M codes.

Emergency facilities coding differs significantly from emergency provider coding. Emergency provider billing refers to the professional services rendered based on the complexity and intensity of such services. Emergency facility billing, by contrast, is based on the volume and intensity of resources required for the care.

Recent reports show a trending shift in how ER facility E/M codes are reported, with a decrease in lower-level codes (99282 and 99283) and a corresponding increase in the two highest-level codes (99284 and 99285). This has caused investigations into the reasons for the shift, policy changes by some payors and ongoing payor/provider disputes as a result.

The American College of Emergency Physicians (ACEP), although an organization for physicians, has developed guidelines providing a general framework for ER facility billing of E/M codes. However, there is no national standard for ER facility billing, and less guidance (and therefore more ambiguity) exists for ER facility coding than for provider coding. Moreover, ER facilities are more often using software or algorithms to assign E/M codes, which may lend themselves to upcoding.

Emergency facility use of the ACEP guidelines and certain algorithms have faced legal challenges, including allegations that they facilitate upcoding and/or do not properly account for variations (such as size, volume, staffing and equipment) among emergency departments. Discovery (including expert discovery) will focus on the use of programs and algorithms to assign coding.

On the payor side, there has been an increase in litigation and arbitrations challenging payor policies intended to ensure accurate coding of ER facility E/M codes. This includes disputes over payors’ use of third-party vendors or software to flag certain high-level E/M claims for medical records and/or downcode high-level codes when certain criteria are met.

Key takeaways
  • Emergency department service disputes remain hot issue with primary focus on facility upcoding of E/M codes to enhance reimbursement
  • Billing of molecular panels warrants increased payor attention; payors should ensure strong medical and coverage policies to prevent abusive billing
  • Remote neuromonitoring is continued area of concern
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