A new policy — which is already being called out by emergency care providers for possibly violating federal law — will enable UnitedHealthcare to retroactively deny claims for emergency department visits.
Beginning July 1, the Minnetonka, Minnesota-based health insurance giant will evaluate ED claims based on three main factors: the condition the patient is presenting with, the type and number of diagnostic services performed and other complicating factors and external causes.
If the payer determines an ED visit is “non-emergent” or not an emergency, it will either not cover the visit or will provide limited coverage. The policy applies to fully insured commercial members in most states.
The purpose behind the policy is to cut emergency room costs and urge members to seek alternate sites of care if they are not experiencing a medical emergency, said Tracey Lempner, director of communications at UnitedHealthcare, in an email.
“Unnecessary use of the emergency room costs nearly $32 billion annually, driving up healthcare costs for everyone,” she said. “We are taking steps to make care more affordable, encouraging people who do not have a healthcare emergency to seek treatment in a more appropriate setting, such as an urgent care center.”
Further, providers will have the opportunity to complete an attestation if they feel the ED visit was an emergency, the policy states. If the attestation is submitted within the required time frame, the claim will likely be processed according to the member’s emergency benefits.
But the American College of Emergency Physicians, which represents more than 38,000 emergency care providers, fears that the policy could hamper clinical care and stop people from going to the ER when they need to.
“In many instances, even physicians do not know if a patient’s symptoms require emergency treatment without undergoing medical examination and tests,” said Maggie McGillick, the association’s director of public relations, in an email. “Our main concern is that dangerous policies such as this will leave millions fearful of seeking medical care.”
The association also believes the policy is in “direct violation of the federal Prudent Layperson Standard, which requires insurance companies to provide coverage of emergency care based on the presenting symptoms that brought the patient to the emergency department, not the final diagnosis,” McGillick said.
But, according to UnitedHealthcare’s Lempner, this is not how the policy will operate. If a UnitedHealthcare member does receive care in the ED for what they think is an emergency but turns out to be a non-emergent issue, like pink eye, the payer will cover the visit per the member’s benefit plan, she said.
This is also where the UnitedHealthcare policy deviates from a similar one implemented by Anthem in 2017, which drew a great deal of criticism. Per the Anthem policy, if the final ED diagnosis is among a predetermined list of non-emergent conditions, the insurer will review the visit and may deny coverage. The UnitedHealthcare policy, on the other hand, will take into account the problem a patient is presenting with, Lempner said, in a phone interview.
“We’re looking at what they came in with,” she said. “We want our members to go into the emergency room if they think they are having an emergency.”
Providers are currently battling Anthem in court over its policy. In 2018, the American College of Emergency Physicians and the Medical Association of Georgia sued Anthem’s Blue Cross Blue Shield of Georgia over the ED claims policy. The suit is ongoing, the American College of Emergency Physicians told Modern Healthcare. The association did not say if they are also planning to sue UnitedHealthcare.
Further, despite the controversy the Anthem policy generated, it may not have been implemented as stringently as expected. In 2017, the payer denied more than 12,000 claims, but reversed most of those when challenged, according to data provided to former Senator Claire McCaskill, the New York Times reported.
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