United HealthCare of Florida has announced plans to scale back its use of claims processing software that automatically downcodes provider claims.
The move came after a Florida Department of Insurance investigation and complaints from the Florida Medical Association.
The software at issue, Patterns, evaluates provider claims sent to United and determines if testing and treatment match diagnoses. The software also automatically downcodes claims from physicians who have been red-flagged for overbilling and upcoding in the past, says Lee Newcomer, M.D., UnitedHealth Group's senior vice president. UnitedHealth Group is the Minneapolis-based parent organization of United HealthCare of Florida.
Florida physicians began complaining about the software last year, and the Department of Insurance launched an investigation in January. In a letter to the department, FMA general counsel John Knight complained that United has engaged in unfair methods of competition and repeatedly downcodes claims without requesting supporting documentation.
A department spokeswoman confirms the investigation is continuing and expects a report later this year.
After the outcry and investigation, United voluntarily reduced the number of Florida physicians whose claims are automatically downcoded to about 100 of the 13,000 doctors it contracts with. Newcomer wouldn't say what the number had been previously.
The software also double-checks claims for level-five services and then downcodes if necessary. According to Newcomer, about 500 of the 13,000 physicians with United contracts in Florida bill level-five codes (which are the most costly) for routine office exams.
He says the alternative is charging physicians with fraudulent billing. "If I came into the office and my diagnosis was an infected toe, but the claim was for a chest X-ray, that wouldn't match up, and that's what is being picked up."