Evaluation and Management Program
Evaluation & Management Services (E&M) are the most common form of care physicians provide to their patients. Unfortunately, due to a combination of provider error and abuse, healthcare payers often make excessive, inappropriate payments on E&M claims.
Waymark Associates has determined that the most common types of improper billing for E&M claims are Upcoding and Modifier 25 abuse.
Upcoding
Because E&M services are billed in ascending levels of complexity, healthcare payers generally pay more for higher levels of service. Some providers, often unwittingly, are systematically and incorrectly billing higher level codes on their E&M claims than were actually rendered, leading to excessive reimbursement from payers.
Modifier 25
Often, an E&M will not be paid when provided with a procedure because the procedure already includes an E&M component within its reimbursement. Providers who believe they are entitled to be paid for an E&M in addition to a procedure bill this by adding Modifier 25 to the E&M claim line. Our analysis indicates that Modifier 25 is added inappropriately to reimbursement requests as much as 35-40% of the time, resulting in excessively high payments.
Overall, we estimate that E&M Upcoding results in healthcare payers overpaying claims by $600 million annually. Moreover, OIG concluded that improper use of Modifier 25 resulted in overpayments in excess of $500 million in 2002.
Helping You Gain Control of E&M Payments
WayMark Associates’ Evaluation & Management Program leads the market in designing and implementing customized solutions to assist healthcare payers in identifying and controlling Upcoding and Modifier 25 abuse. Partnering with your company, we will help eliminate needless E&M overpayments by:
• Analyzing the impact E&M Upcoding and Modifier 25 abuse is
having.
• Developing a comprehensive program that provides maximum return
on investment and minimizes network disruption.
• Helping your team implement procedures to avoid future E&M
overpayments
Our message is this – by implementing the WayMark Associates Evaluation
& Management Program, your organization will reduce its expenditures
for E&M. The overall result can be a substantial improvement in spending
on healthcare claims.
