Claims Adjudication

Looming UnitedHealthcare policy on coverage of emergency department care draws opposition from hospitals, physicians

June 10, 2021 1:27 am
  • UnitedHealthcare soon will start denying claims for ED care that it deems to have been nonemergent.
  • Denials, which could affect 10% of claims, will be subject to further review based on attestations filed by providers.
  • Provider associations are taking strong issue with the new policy.

Leading healthcare provider associations expressed their concerns about a forthcoming coverage policy by UnitedHealthcare (UHC), which recently announced it will take a new approach to assessing emergency department (ED) claims.

UHC, the nation’s leading commercial health insurer by market share, will evaluate claims starting July 1 to determine whether the ED visit was for an emergent or nonemergent event. Cases in the latter category may be covered only partially or not at all. A UHC official estimated that coverage would be denied for 10% of ED visits in accordance with the new policy.

Emergency claims will be assessed based on:

  • The patient’s presenting problem
  • The intensity of diagnostic services performed
  • Other patient complicating factors and external causes

When an ED visit is initially considered nonemergent, the hospital or health system can submit an attestation that the patient’s visit met the definition of emergency based on the prudent layperson standard, which was established by the 1986 Emergency Medical Treatment and Labor Act.

The attestation will be transmitted to the provider electronically following a determination that the care was nonemergent. Among the health system representatives who can complete the attestation are the attending physician, the medical director or nursing director of the ED, or another healthcare professional designated by the facility.

“If the attestation is submitted within the required time frame, the claim will typically be processed according to the plan’s emergency benefits,” UHC wrote in its post about the coverage policy.

The coverage policy will apply in the majority of states at the outset and will expand subject to regulatory approval.

In a statement provided to HFMA, UHC gave additional explanation about the new policy:

“Unnecessary use of the emergency room costs nearly $32 billion annually, driving up healthcare costs for everyone. We are taking steps to make care more affordable, encouraging people who do not have a healthcare emergency to seek treatment in a more appropriate setting, such as an urgent care center.

“If one of our members does receive care in an emergency room for a nonemergent issue, like pink eye, we will reimburse the emergency facility according to the member’s benefit plan.”

Concerns about adverse impacts on patients

The American Hospital Association (AHA) and American College of Emergency Physicians (ACEP) each is petitioning UHC to reverse the policy.

In a letter signed by President and CEO Rick Pollack, the AHA wrote, “Threatening patients with a financial penalty for making the wrong decision could have a chilling effect on seeking emergency care. … This is exactly why federal law requires insurers to adhere to the prudent layperson standard, which prohibits insurers from putting up coverage roadblocks to emergency services, such as by determining retroactively whether a service will be covered based on the patient’s final diagnosis.”

Provider groups are concerned that denying coverage and subsequently requesting an attestation doesn’t comply with the prudent layperson standard and is bound to make members more hesitant to seek care. It would also add to a provider’s administrative burden.

The AHA asked for written confirmation that UHC would cover any services for which a hospital or health system attests that the prudent layperson standard was met.

In a statement posted to its website, ACEP cited CDC statistics showing that only 3% of ED visits are nonurgent and 90% of symptoms overlap between nonurgent and emergent conditions.

“UnitedHealthcare is expecting patients to self-diagnose a potential medical emergency before seeing a physician, and then punishing them financially if they are incorrect,” Mark Rosenberg, DO, MBA, president of ACEP, said in the statement.

AHA and ACEP both noted that patients have suffered due to deferred care during the COVID-19 pandemic, saying UHC’s coverage policy could exacerbate the trend.

“This new policy will leave millions fearful of seeking medical care, just as we’re getting hold of the COVID-19 pandemic and trying to get as many people vaccinated as possible,” Rosenberg said.

Seeking to tamp down on unnecessary care

UHC said the objective of the new policy is to reduce unnecessary ED utilization and not to dissuade patients from seeking essential care. The insurer wants to encourage its members to consider alternate care settings and virtual care options when not facing a genuine health emergency, a UHC official said in an interview.

“This really focuses on pinpointing those events that are most clearly nonemergent,” the official said, speaking on background.

If a member goes to the ED with chest pain and receives a final diagnosis of heartburn, the official said, the visit would be covered once the provider attests that the case met the prudent layperson standard.

From a cost standpoint, ED visits can amount to nine times more than an urgent care visit and 35 times as much as a virtual appointment, the official said.

“If someone goes to the emergency room for minor illnesses and injuries, there are resources that are being pulled from people with emergencies in that emergency room,” the official said. “Using an emergency room for all their care needs [also] can be a barrier to care because they don’t develop long-term relationships with their primary care physician.”

In its letter, AHA disputed the notion that unnecessary ED care is rampant.

“UHC may believe inappropriate use of the emergency room is a widespread problem; however, there is limited evidence to support this view,” Pollack wrote.


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