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A proven approach to preventing E&M over-coding

Cotiviti Chief Medical Officer Richard Pozen, M.D., explains how payers can tackle challenging Level 4 and 5 E&M claims while still paying claims promptly and minimizing abrasion.

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Evaluation and Management (E&M) services are the backbone of most physician practices, comprising up to 35% of office-based claim payments for physician services in the United States, also known as professional claims. Based on both objective and subjective criteria to determine the complexity of the visit, a provider chooses the appropriate level for each code—and the higher the level, the greater the reimbursement.

It’s no surprise, then, that E&M claims comprise a significant payment integrity challenge for payers. The problem also extends to emergency room (ER) facility E&M claims. A Cotiviti analysis across commercial, Medicare, and Medicaid clients demonstrates a significant rise in Level 4 and 5 claims submitted in the last five years and a corresponding decrease in lower-level claims. Given this increase, there is a major likelihood of over-coding and inflated costs that can be difficult to recover.

In a new white paper, Cotiviti Chief Medical Officer Richard Pozen, M.D.,  explains how an approach that combines machine learning and advanced analytics with expert nurse coder review delivers significant savings for payers—and enables them to pay even the most complex E&M claims promptly and appropriately while minimizing the potential for provider pushback.

About the Author

Dr. Richard Pozen is an expert in clinical coding and works extensively with Cotiviti’s clients and their medical directors. He was a co-founder of iHealth Technologies, one of Cotiviti’s original predecessors, and has extensive experience on both the payer and provider sides of healthcare. After running a private practice for 14 years, he created Cardiology Network, Inc., to provide specialty management services to healthcare payers. He subsequently held leadership positions at Vivra Specialty Partners and Magellan Specialty Health.

Profile Photo of Richard Pozen, M.D.