UnitedHealthcare temporarily reverses ER claims denial policy after backlash

Photo: SCIENCE PHOTO LIBRARY/Getty Images

UnitedHealthcare, the nation's largest health insurer, has backtracked on a proposed policy retroactively rejecting emergency department claims.

The policy, which was slated to take effect on July 1, meant UHC would evaluate ED claims to determine if the visits were truly necessary for commercially insured members. Claims deemed non-emergent would have been subject to "no coverage or limited coverage," according to the insurer.

The move, however, resulted in plenty of backlash. The American Hospital Association objected to the policy, saying the retroactive denial of coverage for emergency-level care would put patients' health in jeopardy.

"Patients are not medical experts and should not be expected to self-diagnose during what they believe is a medical emergency," the group wrote in a letter this week to UnitedHealthcare CEO Brian Thompson. "Threatening patients with a financial penalty for making the wrong decision could have a chilling effect on seeking emergency care."

The policy also created a stir on Twitter, 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.

It was this backlash, according to a report from The New York Times, that prompted UHC to roll back the policy – for now. The insurer told the Times that the policy would be stalled until the end of the ongoing COVID-19 pandemic, whenever that might be.

A request for comment by UHC was not immediately returned.

WHAT'S THE IMPACT?

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.

In making the initial announcement of the policy change, UHC cited those statistics as the driving factor behind the decision. But skeptics and industry analysts, including the AHA, claim that the policy was actually intended to curb UHC's own costs.

Statistics show that many Americans have delayed or avoided medical care during the pandemic, and the concern in the industry and among provider groups was that UHC's claims policy would endanger health by disincentivizing people from seeking emergency care when they may need it.

The AHA responded Thursday to UHC's decision to delay the rule, saying that while it offers a temporary reprieve for patients, it should be reversed fully and on a permanent basis.

"It is ... part of an unfortunate pattern of commercial health insurers denying care for needed services," the AHA said in a statement issued Thursday. "Patients should have the confidence to seek the emergency care they need without worrying about coverage being denied. There is no justification for these restrictions now or after the public health emergency."

If the policy change still takes effect after the pandemic ends, as is the plan, the policy would apply to millions of Americans enrolled in UHC's fully insured plans in 35 states. Those covered through a self-insured employer or enrolled on Medicaid or Medicare Advantage would not be affected, and exemptions exist for children younger than age 2.

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.

UnitedHealth Group, for its part, beat industry projections by earning $4.9 billion in profit during the first quarter of 2021, according to an April earnings report. That's an increase of $3.4 billion from the same quarter in 2020.

Revenues hit $70.2 billion, up 9% compared to the first quarter of this year, when it posted $64.4 billion in revenues. UHG said its growth was "balanced" across subsidiaries UnitedHealthcare and Optum. Revenues grew 7.9% year over year, hitting $55.1 billion, a $4 billion increase from Q1 2020.
 

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