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Insurance Subsidiaries Working Both Ends With Billing and Auditing Functions…

Posted Jul 10 2014 5:27am

It’s hard to keep track of who owns who anymore and here’s a good example of an Optum owned company that was bought by United about 4 years ago for 1.5 Billion and with reviewing claim denials it’s working both sides. You wonder at times if they are reviewing denied claims from United, right and have income in that respect.   In addition there’s compliance services that work with RAC auditors as another service and there’s plenty of other things under the hood here too. 

“Founded in 1997, EHR, The Physician Advisor Company™, is nationally recognized as the leading provider of real-time, point of care, expert Physician Medical Management Solutions that improve hospital revenue integrity and maintain the highest level of quality of care and regulatory compliance. EHR's expert physicians, the EHR Physician Advisors, provide hospitals and health systems with an outsourced operational, technological, and clinical resource to achieve the hospital’s goal of effectively managing clinical care while maintaining sound financial performance.”
UnitedHealthGroup On The Move to Potentially Purchase Executive Health Resources for Around 1.5 Billion – Too Big To Fail or Is It Too Big to Insure?

Even 4 years ago I was concerned about one insurance company growing so large as it was one of 5 made during the early part of 2010.  I bet there’s hospitals that are not even aware that this company is part of the big United Group.  In addition, it’s another service that hospitals have to pay for with the complex billing systems we have today.  BD 


And one of the nation’s largest health insurers appears to be covering all the angles. As an insurer and a company offering private Medicare Advantage plans, the UnitedHealth Group boasts of its ability to provide quality care at a lower cost. It often pays doctors and hospitals less than requested, highlighting the savings it achieves.

But UnitedHealth also owns a little-known consultant that is flourishing by helping hospitals exploit what they describe as a gray area in Medicare payments for hospital stays, fighting to get what can amount to thousands of dollars more per patient.

The consultant, Executive Health Resources, is often at the center of battles between hospitals and Medicare over how the facilities bill.

In June, the University of Cincinnati Medical Center was hit by a government audit that said it should return nearly $10 million to Medicare, largely the result of claims the auditors rejected as inpatient stays. Those include so-called short stays where a patient might be in the hospital for less than a day or two. Executive Health is under contract to review claims for the medical center and will be part of the appeal, according to the center.

The center is aggressively contesting the government’s findings, arguing its methods are flawed. It also says the conclusions “relate to technical requirements for billing Medicare, not to the appropriateness or quality of the services.”

In making its pitch to hospitals, Executive Health emphasizes what it calls a “gray area” in Medicare rules, estimating in a 2012 presentation that it was worth nearly $80 billion. It also points to overwhelming success in appealing cases that were initially denied as inpatient care, like patients with chest pain who later had normal test results or those who had elective heart procedures like angioplasties. The company says it follows Medicare guidance.

How a visit is classified also affects patients, who may owe different amounts because the stays are paid under different parts of Medicare. The rules require patients to have three days of inpatient care before the program will pay for skilled nursing care.

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