Healthcare Legal Solutions, LLC Addresses Improper Use of EDC Analyzer by Kaiser Permanente Mid-Atlantic States.

Washington, District of Columbia (February 26, 2025)- Kaiser Permanente Mid-Atlantic States (“KP-MAS”) started using Optum® Emergency Department Claim (“EDC”) Analyzer for outpatient Emergency Department claims that are submitted with Levels 4 and 5 evaluation and management (“E/M”) codes (99284 and 99285) in January 1, 2024, for Maryland facilities.

The EDC Analyzer claims to “achieve fair and consistent evaluation and management coding and reimbursement of facility outpatient emergency department (ED) claims.” In reality, however, it often suggests a lower E/M code, usually 99283 and 99282, by solely analyzing the Uniform Bill (“UB”) without taking into consideration any extenuating factors that may have accompanied the patient’s presentation at the ED. Moreover, KP-MAS—after suggesting a lower E/M code— arbitrarily and frequently reimburses the facility without the facility initiating a rebill. This caused not only a denial of the services provided but also improper underpayment.

Committed to reversing these improper payment determinations, Healthcare Legal Solutions, LLC (“HLS”) diligently mounted a legal campaign with its Maryland hospital clients to address KP-MAS’ practices. HLS argued that these practices were contrary to the policies of the Maryland’s Health Services Cost Review Commission (“HSCRC”), which is tasked with setting rates for hospital services for all payers in Maryland. Thanks to HLS’ zealous representation of its Maryland hospital clients, KP-MAS has agreed to halt the use of the EDC Analyzer for claims submitted by those hospitals.  

We appreciate KP-MAS’ quick attention to the matter and eagerness to rectify the issue. It remains unclear whether this change impacts all facilities that provide ED services in Maryland, but it is an encouraging step to ensure that hospitals and facilities get reimbursed fully for the services that they provide.

For more information on how HLS may help your hospital system in combating improper payment determinations, please contact Desiree Charpentier at DCharpentier@hlsllc.com.

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HLS LLC’s mission is to help healthcare providers maximize reimbursement for their services. By increasing and accelerating payments from third party payers, we enable healthcare providers to focus on their core business of patient care. Our professional and experienced staff assists healthcare providers in meeting their financial requirements, while minimizing the financial liability of patients. For more information, please contact Desiree Charpentier or visit HLSLLC.com.