The American Hospital Association has sent a letter to UnitedHealthcare urging the health insurer to rescind a new policy that would allow it to retroactively reject emergency department claims.

As part of the new policy, UnitedHealthcare, the insurance arm of UnitedHealth Group, is now evaluating ED claims to determine if the visits were truly necessary for commercially insured members. Claims that are deemed non-emergent – meaning not a true emergency – will be subject to “no coverage or limited coverage” beginning on July 1.

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.

The AHA has objected to this 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 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.”

What could exacerbate that effect, the AHA contended, is the ongoing COVID-19 pandemic, which has spurred a rash of deferred and delayed care and in turn has contributed to adverse health outcomes and increased acuity.

The AHA noted that federal law requires insurers to adhere to the “prudent layperson standard,” which prohibits insurers from limiting coverage for emergency services. That’s exactly what UnitedHealthcare is doing, the group said, by retroactively determining whether a service will be covered based on the patient’s final diagnosis.

The AHA also targeted what it believes is vague language on the UHC website that could confuse patients as to when it’s appropriate to access emergency services. The site urges patients not to ignore emergencies and to call 911 or head to the ED immediately if they believe a situation is life threatening. But then, in the AHA’s estimation, it “over-generalizes” symptoms that are appropriate for urgent care, including stomach pain, nausea and vomiting.

There are a number of factors UnitedHealthcare hasn’t considered, according to the AHA, such as whether enrollees have enough providers available during non-traditional hours, whether UHC has helped enrollees connect with a primary care provider, and whether its networks offer sufficient access to alternative sites of care. Moreover, the AHA has asked UnitedHealthcare to confirm in writing that services will be covered if they meet the prudent layperson standard.

Not stopping at retroactive ED claims denials, the AHA also questioned other UHC policies that it believes may contribute to access challenges.

“For example, UHC has announced policies that would reduce or eliminate coverage for certain hospital-based surgeries, laboratory and other diagnostic services, specialty pharmacy therapies, and evaluation and management services, including those provided in the emergency department, as well as those that constitute primary care,” the AHA wrote. “If UHC is successful in denying coverage for these services in hospital outpatient departments, it could exacerbate UHC’s concerns regarding emergency department use.”

WHAT’S THE IMPACT

According to UnitedHealthcare’s new policy, 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.

The AHA isn’t the only voice criticizing the new policy. Twitter exploded 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.

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: [email protected]



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