‘Chilling effect on patients’: Following backlash, insurance giant UnitedHealthcare delays policy to scrutinize ER claims


Faced with mounting criticism from hospitals and doctors’ groups, health insurance giant UnitedHealthcare said it would delay a policy that would check payment for non-essential emergency room visits.

The policy of reviewing and potentially closing some hospital payments sparked outrage from the American Hospital Association and the American College of Emergency Physicians about potential harm to patients’ health and finances.

In a statement on Thursday, the Minnesota-based insurer said the policy would be put on hold until the end of the pandemic.

“Based on discussions with our provider partners and medical societies, we have decided to delay the implementation of our emergency department policy until at least the end of the national public health emergency period,” said Tracey Lempner, spokeswoman for the Minnesota-based insurance company. ” , said in a statement.

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Officials from the American Hospital Association urged the insurer to drop the policy altogether. If enacted, the policy “would have a chilling effect on patients seeking emergency services, with potentially serious consequences for their health,” said Rick Pollack, president and CEO of the hospital group.

Similarly, 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 if UnitedHealthcare refuses them.

UnitedHealthcare this month Told its network hospitals in 34 states that it would assess emergency room claims To determine whether the seizures were really medical emergencies.

According to the insurer’s notice sent to hospitals, under the now-delayed policy, claims that are determined not to be tied to an emergency will be subject to no coverage or limited coverage depending on the patient’s insurance plan. Lempner, a spokesperson for the Minnesota-based insurer, said 1 in 10 claims could be denied

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

Experts say health insurers often conflict over payment policies with hospitals and emergency care providers over the rising cost of medical care. Hospitals have higher overhead costs and typically charge more for similar procedures, said Benedick Ippolito, a resident scholar and health economist at the American Enterprise Institute.

“Insurers have a huge incentive to try and steer people to the most cost-effective sites of care,” Ippolito said. “In concept, the idea is sound … whether it is the right way to do it is a different question.”

A key point for COVID telehealth was: If doctors and patients have their way, virtual tours are here to stay.

Lempner said unnecessary use of emergency rooms costs $32 billion annually and increases health care costs for all.

“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 receives care in an emergency room for a non-emergent issue such as pink eye, we will reimburse the emergency facility according to the member’s benefit plan.”

In a notice to hospitals announcing the now-delayed policy, UnitedHealthcare says that emergency room claims are evaluated based on the patient’s presenting problem, the intensity of clinical services performed, and other patient complicating factors and external causes. on will be done.

When claims are denied, hospitals may present evidence that an emergency room visit meets the definition of an emergency that conforms to the prudent layperson standard according to the insurer’s notice.

According to a June 8 statement regarding UnitedHealthcare’s new policy, the National Emergency Physicians’ Group believes the delayed policy is a direct violation of the federal layperson standard.

According to the Physicians Group, the federal policy requires insurance companies to provide coverage of emergency room care based on presenting symptoms that bring a patient to the emergency room, not a final diagnosis.

“While we are disappointed with United’s decision, unfortunately, we are not surprised to see an insurance company once again trying to cut its costs at the expense of needed patient care,” said Dr. Mark, president of the Emergency Physicians Group. Rosenberg, said in a statement.

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

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

The physicians’ group noted that 90% of symptoms overlap between non-urgent and emergency situations, in many cases physicians may not even know whether a patient’s symptoms require emergency treatment without conducting extensive medical examination.

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

Wooster of the physicians’ group said UnitedHealthcare’s new policy is more harmful to patients in several states than the policy adopted by Anthem in 2018, leading the emergency physicians’ group to file a lawsuit against Anthem, which is still pending. is.

When the insurer decided that the member did not want to face an emergency, Anthem in some states began refusing to pay for emergency room services. This left patients stuck with bills.

“They’ve taken it back in a big way,” Wooster said. “They’re not enforcing it.”

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