Journal of Urgent Care Medicine

UnitedHealthcare Plans Nix Code S9083 Global Fee Urgent Care Center in New Jersey

UnitedHealthcare Commercial in New Jersey and UnitedHealthcare Oxford of New Jersey will stop reimbursement of HCPC code S9083 as of January 1, 2018, according to a letter sent to providers. Instead, the plans are advising providers to “only report the evaluation and management and/or procedure code(s) that specifically describe the service(s) performed.” S9083, they say, is “informational” and relates to a type of reimbursement rather than a specific service. Charges billed for S9083 will be …

Cigna Will Stop Covering OxyContin Prescriptions

Cigna has announced that it will no longer cover prescriptions for the opioid medication OxyContin, and is recommending that patients who take it confer with their doctors to find an alternate pain drug. Cigna will, however, cover the alternative opioid drug Xtampza ER. The company says the move is in line with its “focus on helping customers get the most value from their medications”—which in this case extends to “obtaining effective pain relief while also …

CMS Ups Its Game in Going After Medicare Fraud

Recent headlines have put Medicare fraud—and the search for those committing it—in the spotlight. However, urgent care clinicians who toe the line in treating Medicare patients are less likely to face unwarranted audits in the future—while fraudsters are putting themselves more at risk than ever—under a new system revealed by the Centers for Medicare and Medicaid Services (CMS). The agency is essentially narrowing the scope of practices it will investigate for fraud, hoping it will …

Follow-up: AMA Cries Foul over New Anthem ED Policy

We’ve told you recently about plans some insurers have to stick patients with the bill for emergency room visits that are retrospectively determined to have been nonemergent in nature. In essence, if patients go to the ED with an illness or injury that could have been handled in a lower-acuity setting (such as an urgent care center), as determined by the insurer, the patient’s claim will be denied. Now the American Medical Association is demanding …

Cigna Moves to Keep Members Away from Urgent Care

Cigna is collaborating with CVS Health to push members into retail clinics instead of visiting urgent care centers when they have immediate, nonemergent medical needs. The company claims that around 45% of urgent care visits could be handled in drugstore clinics—at a savings of 81% per visit for Cigna. The problem? Cigna’s data highlight the minority of patients seeking care. The majority (55%) could not be treated sufficiently in the retail setting, meaning they’d end …

UnitedHealth Sees Growth After Exiting ACA Markets

UnitedHealth Group Inc. was very open in its claims that it was impossible to sustain the economics of participating in healthcare exchanges under the Affordable Care Act (ACA, or “Obamacare”)—and thus the company would stop participating. It made good on that vow, and has now reported profit growth in the second quarter and raised its projections for the year, fueled by its Optum health-services arm. The largest insurer in the U.S. UnitedHealth has almost completely …

E/M Coding Could Be Heading for an Overhaul

The Centers for Medicare and Medicaid Services says providers have been clamoring for an update of the 1995 and 1997 guidelines for evaluation-and-management (E/M) codes—and it may be ready to oblige them. If it goes forward, the plan would take years to implement and focus mainly on revising the history and physical exam portion of a patient encounter. The aim, according to CMS, would be to simplify and better align E/M coding and documentation, presuming …

CMS May Cut Payments for Off-Campus Hospital Visits by Half

Hospital-owned urgent care centers—many of which became “hospital-owned” thanks to a relatively generous 50% reimbursement rate for off-campus patient visits—may be taking a substantial hit if the Centers for Medicare and Medicaid Services follows through on a plan to cut that rate by half. Hospital administrators say even though running off-campus clinics increases their operating budgets, they enable health systems to offer more patients access to cost-effective care. On the other hand, the Trump administration …

Trustees Extend Medicare ‘Doomsday Scenario’ by a Year

Trustees for the actual Medicare trust fund say it will be insolvent by 2029, a year later than predicted by the Obama administration last year. The year before that, the Congressional Budget Office foresaw the program running dry in 2026. This means the infamous Independent Payment Advisory Board—devised by the designers of the Affordable Care Act (ACA, or “Obamacare”) to put the brakes on Medicare spending if costs grew faster than a predetermined rate—will not …

Attention Small Urgent Care Operators: CMS May Lower Threshold for MACRA Exemptions

Centers for Medicare & Medicaid Services has broadened the definition of “small providers” as it applies to the Medicare Access and CHIP Reauthorization Act of 2015, to the extent that physician practices with less than $90,000 in Medicare revenue or fewer than 200 unique Medicare patients per year would be exempt from having to comply with MACRA. Between this new standard and the one proposed for next year, the move will exclude roughly 834,000 more …