June 22, 2021

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Insurance giant’s new ER policy called ‘dangerous’ by critics. It says as many as 1 in 10 claims could be rejected.

5 min read

Insurance giant UnitedHealthcare is cracking down on emergency room visits with a new policy starting July 1 that the American Hospital Association says will jeopardize patients’ health and threaten them with financial penalties.

The American College of Emergency Physicians said it fears the change will cause patients to avoid using emergency rooms because they will be responsible for their hospital bills when UnitedHealthcare rejects them.

UnitedHealthcare this month told its network hospitals in 34 states including Florida that it will assess emergency room claims to determine if visits were indeed medical emergencies.

Claims that are determined not to be tied to emergencies will be subject to no coverage or limited coverage based on the patient’s insurance plan, according to the insurer’s notice sent to hospitals. As many as 1 in 10 claims could be rejected, said Tracey Lempner, spokeswoman for the Minnesota-based insurer.

UnitedHealthcare’s policy affects commercially insured patients with employer-sponsored plans and does not apply to patients with Medicare Advantage or contracted Medicaid coverage with UnitedHealthcare, Lempner said.

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UnitedHealthcare in 2018 said it had more than 30 million Americans with commercial or employer-sponsored plans.

“If the event is determined to not be an emergency, the claim will be paid based on the member’s benefits,” Lempner said, adding, “We estimate that nationally less than 10% of (Emergency Department) claims will be classified as non-emergent through this program.”

The policy will take effect in 34 states and the District of Columbia, Lempner said. They are: Alabama, Arizona, Arkansas, Colorado, Connecticut, Washington, D.C., Delaware, Florida, Georgia, Indiana, Iowa, Kansas, Kentucky, Louisiana, Maryland, Massachusetts, Michigan, Mississippi, Nebraska, Nevada, New Hampshire, New Jersey, New York, Ohio, Oklahoma, Oregon, Pennsylvania, South Carolina, Tennessee, Texas, Utah, Virginia, Washington, West Virginia and Wisconsin.

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National groups object 

The policy applies to the hospital portion of emergency room care, so patients could be billed when the claim is denied, said Laura Wooster, associate executive director of public affairs for the emergency physicians organization based in Washington, D.C.

“If United doesn’t cover it, then the patient will be on the hook,” she said. “It looks like they are not on the hook for the (emergency physicians’ bill). We are trying to get more information on that.”

She could not say if other insurers will adopt a similar policy.

Steve Zucker/News-ReviewUnlike the big red letters leading the way to McLaren Northern Michigan hospital's emergency department, it isn't always easy to read when a health condition calls for a trip to the emergency room.

“I’m sure they will be keeping an eye on it,” she said.

This is not the first time that insurers have adopted policies to deny claims from emergency rooms, often the costliest source of medical care.

Indianapolis-based Anthem adopted a similar policy in 2018 that is the subject of a lawsuit by the emergency physicians group, she said. And UnitedHealthcare in 2018 began reducing emergency room claims when it determined coding was inappropriate.

The American Hospital Association is calling on UnitedHealthcare to immediately reverse the new policy, President and CEO Richard Pollack said in a June 8 letter to the insurer.

The insurer’s parent company, UnitedHealth Group, earned $6.7 billion in the first quarter of the year, according to the hospital association.

“Patients are not medical experts and should not be expected to self-diagnose during what they believe is a medical emergency,” Pollack said in his letter. “Threatening patients with a financial penalty for making the wrong decision could have a chilling effect on seeking emergency care.

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“This is dangerous for patients’ health at any time, but is particularly unsafe in the midst of a public health emergency,” he said, referring to the COVID-19 pandemic.

“UHC may believe inappropriate use of the emergency room is a widespread problem; however, there is limited evidence to support this view,” Pollack said.

UnitedHealthcare defends policy

Lempner said unnecessary use of emergency rooms cost $32 billion annually and drives up health care costs for everyone.

“We are taking steps to make care more affordable, encouraging people who do not have a health care emergency to seek treatment in a more appropriate setting, such as an urgent care center,” she said.

“If one of our members does receive care in an emergency room for a non-emergent issue, like pink eye, we will reimburse the emergency facility according to the member’s benefit plan,” she said.

In the notice to hospitals, UnitedHealthcare says emergency room claims will be evaluated based on the patient’s presenting problem, the intensity of diagnostic services performed and other patient complicating factors and external causes.

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When claims are denied, hospitals can submit evidence an emergency room visit met the definition of an emergency that is consistent with the prudent layperson standard, according to the insurer notice.

The national emergency physicians group believes the new policy is in direct violation of the federal layperson standard, according to a June 8 statement about UnitedHealthcare’s new policy.

The federal policy requires insurance companies to provide coverage of emergency room care based on the presenting symptoms that brought the patient to the emergency room and not the final diagnosis, according to the physician group.

“While we’re dismayed by United’s decision, we are not, unfortunately, surprised to see an insurance company once again try to cut its costs at the expense of necessary patient care,” Dr. Mark Rosenberg, president of the emergency physicians group, said in a statement.

“UnitedHealthcare is expecting patients to self-diagnose a potential medical emergency before seeing a physician, and then punishing them financially if they are incorrect,” Rosenberg said.

According to the Centers for Disease Control and Prevention, 3% of emergency room visits are nonurgent, the emergency physicians group said.

Dr. Leon L. Haley Jr., a board-certified emergency room physician, CEO of UF Health Jacksonville and dean of the UF College of Medicine – Jacksonville, is among the first in Florida to be vaccinated on Monday.

With 90% of symptoms overlapping between non-urgent and emergent conditions, in many instances even physicians cannot know if a patient’s symptoms require emergency treatment without conducting a comprehensive medical examination, the physicians group said.

UnitedHealthcare’s Lempner said the policy complies with federal regulations and the layperson standard.

UnitedHealthcare’s new policy is more detrimental to patients than the one adopted by Anthem in 2018 in many states that led the emergency physicians group to file the lawsuit against Anthem that is still pending, said Wooster of the physicians group.

Anthem began denying payment for emergency room services in a handful of states when the insurer decided the member did not face an emergency. As a result, patients were getting stuck with the bills.

“They have largely rolled it back,” Wooster said. “They are not enforcing it.”

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