UnitedHealthcare looks to retroactively deny emergency room claims

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UnitedHealthcare is reexamining its policy on emergency department visits, and is now evaluating ED claims to determine if the visits were truly necessary for commercially insured members, the nation's largest insurer recently revealed in a notice on its website.

Claims that are deemed non-emergent – meaning not a true emergency – will be subject to "no coverage or limited coverage" beginning on July 1, UnitedHealthcare said. To determine whether this is the case, the insurer will evaluate ED claims based on factors including the patient's presenting problem, the intensity of diagnostic services performed and other criteria.

If an ED event is determined to be non-emergent, there will be the opportunity for attestation, which will be sent electronically to the facility in question. If processed in the required time frame, the claim will be processed according to the plan's emergency benefits.

This means the amount paid by UnitedHealthcare may be less for incidents it determines are non-emergent.

WHAT'S THE IMPACT?

The move caused controversy on Twitter this week, with many saying it could inspire hesitancy in patients even for events that are true emergencies, such as heart attacks. That would, in effect, lead to lower reimbursement for some providers, who are still struggling to regain financial health after delayed and deferred care during the COVID-19 pandemic caused revenues to sink.

Still, internal data from UnitedHealth Group, UnitedHealthcare's parent company, points to the very real problem of ED misuse, which costs the U.S. healthcare system roughly $32 billion annually. Misuse typically manifests as patients seeking out costly ED care for minor ailments that could have been addressed through other avenues.

The policy is ostensibly an attempt to curb healthcare costs – and UHC's costs – by guiding patients to urgent care facilities and other settings.

It contains exclusions, including visits by children under two years, observation stays and admissions from the ED. UnitedHealthcare currently boasts northwards of 26 million commercial members.

A request for comment from UnitedHealth Group was not immediately returned.

THE LARGER TREND

The move is not a first for a major insurer. Anthem instituted a similar policy in 2017, deciding not to cover certain ED visits if the precipitating incident was deemed to not be an emergency. Anthem backtracked on this policy somewhat the following year after objections poured in from providers, who said patients are put in harm's way when they have to decide whether their conditions constitute an emergency.

On January 1, 2018, Anthem said it would always pay for ER visits based on certain conditions. These exceptions include provider and ambulance referrals, services delivered to patients under the age of 15, visits associated with an outpatient or inpatient admission, emergency room visits that occur because a patient is either out of state or the appropriate urgent care clinic is more than 15 miles away, visits between 8 a.m. Saturday and 8 a.m. Monday, and any visit where the patient receives surgery, IV fluids, IV medications, or an MRI or CT scan.

A 2019 study suggests that Medicaid expansion may play a role in diverting patients from EDs and toward primary care options. The study compared ED use in states that expanded Medicaid under the Affordable Care Act with that of non-expansion states, and found that in Medicaid expansion states patients shifted their use of the ED toward conditions that required subsequent hospitalization, and predominantly for illnesses that were not easily avoided by robust outpatient care.

Those findings indicate that newly insured patients may be relying more on outpatient care for less severe conditions, affecting utilization by avoiding unnecessary ED visits – effectively freeing up hospital EDs for their intended purpose.

Twitter: @JELagasse
Email the writer: jeff.lagasse@himssmedia.com