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


The insurance company is UnitedHealthcare Cracking down on emergency room visits With a new policy starting July 1, the American Hospital Association says it will put patients’ health at risk and threaten 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 if UnitedHealthcare refuses them.

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

According to the insurer’s notice sent to hospitals, 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. Tracey Lempner, spokeswoman for the Minnesota-based insurer, said 1 in 10 claims could be dismissed.

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.

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

“If the event is not considered an emergency, the claim will be paid based on the member’s benefits,” Lempner said, adding that “we estimate that at the national level (the emergency department) less than 10% of claims will be made for non-profits.” will be classified as emerged through this program. “

Lempner said the policy would be in effect in 34 states and the District of Columbia. They are: Alabama, Arizona, Arkansas, Colorado, Connecticut, Washington, DC, 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.

national group objection

The policy applies to the hospital’s portion of emergency room care, so patients can be billed if a claim is denied, said Laura Wooster, associate executive director of public affairs for the Organization of Emergency Physicians based in Washington, D.C. .

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

She could not say whether other insurers would adopt a similar policy.

Steve Zucker/News-Review McLaren Unlike the big red letters that pop up on the way to the emergency department of Northern Michigan Hospital, it's not always easy to read when a health condition calls for an emergency room visit.

“I’m sure they’ll keep an eye on it,” she said.

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

The Indianapolis-based Anthem adopted a similar policy in 2018 that is the subject of a lawsuit by a group of emergency physicians, she said. And UnitedHealthcare began reducing emergency room claims in 2018 after it was determined the 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, generated $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 a medical emergency,” Pollack said in his letter. “Threatening patients with financial penalties for making the wrong decision can have a chilling effect on receiving emergency care.

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“It is dangerous to the health of patients at any time, but is particularly vulnerable amid a public health emergency,” he said, referring to the COVID-19 pandemic.

“The UHC believes that 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 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 for a non-emergent issue such as pink eye in the emergency room, we will reimburse the emergency facility according to the member’s benefit plan,” she said.

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

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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 new 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.

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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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