AHA asks UnitedHealthcare to rescind revised policy on emergency coverage

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UnitedHealthcare recently announced it would move forward with new coverage criteria for emergency-level care, which went into effect January 1, and this has drawn the ire of the American Hospital Association, which is urging UHC to rescind the policy.

Beginning January 1, UHC began reviewing claims for emergency services to evaluate whether a patient should access care in the emergency department. If UHC believes that emergency-level care isn't warranted, it may deny the claim.

"The result is that either patients must then pay for their care without any assistance from their health plan, or the emergency department and clinicians who care for the patient forego billing and absorb the loss of reimbursement," the AHA wrote in a letter to UHC.

The hospital advocacy group said that because UHC announced the change after many people had already selected their health plans for the year, patients will likely be caught unaware when coverage is denied for emergency care.

The AHA expressed a number of concerns – chief among them that the new coverage criteria comes six months after UHC said publicly that it would implement a new emergency service coverage policy until at least the end of the public health emergency. With COVID-19 case counts on the rise once more, the AHA maintains that the PHE is far from over.

Another issue is that, while the AHA considers the new coverage criteria to be a slight improvement over what UHC sought to implement over the summer, which would have retroactively rejected emergency department claims, it has a caveat that may undermine any improvements.

"The improvements include an acknowledgement by UHC of the importance of considering the symptoms that the patient believed warranted emergency care and not just the final diagnosis, which can only be determined after an examination by a medical professional and relevant diagnostics," the AHA wrote.

But the group said UHC will continue to take into account both the final diagnosis and "other pertinent information," which it fails to fully specify. Absent that specificity, the new coverage criteria could have the same detrimental effect on patients and providers as the original policy, the organization contends.

WHAT'S THE IMPACT?

The AHA is concerned about the potential impact this would have on both patients and providers.

"Like its predecessor, this new policy will make patients much more reluctant to seek needed emergency care out of fear of a coverage denial and will add substantial paperwork burden on the providers who treat them," the group wrote.

The AHA also believes the policy will overburden hospitals' clinical workforce at a time when demands on healthcare workers are already considerable, pulling clinicians away from the bedside to collect, review and submit paperwork. 

This would contribute to the risk of administrative burden, "as this policy allows UHC to manipulate its coverage criteria through the vague criterion of 'other pertinent information,'" according to the group. "Failure to clearly establish coverage criteria leaves both patients and providers in the dark, and such ambiguous terms will almost certainly result in providers being asked to send to UHC voluminous amounts of paperwork to satisfy whatever information it requests in order to approve coverage."

The AHA cited statistics indicating that there are 450,000 fewer healthcare workers nationally than in February 2020.

A request for comment by UHC was not immediately returned.

THE LARGER TREND

In June 2021, UHC 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 AHA objected to the policy from the start, saying the retroactive denial of coverage for emergency-level care would put patients' health in jeopardy.

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.

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.
 

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