The new emergency policy of the insurance giant described as “dangerous” by critics. It indicates that up to 1 in 10 complaints could be rejected.

Insurance giant UnitedHealthcare is cracking down on emergency room visits with a new policy effective July 1 that the American Hospital Association says will put patients’ health at risk and threaten them with financial penalties.

The American College of Emergency Physicians said it fears the change will prevent patients from using emergency rooms because they will be responsible for their hospital bills when UnitedHealthcare rejects them.

UnitedHealthcare this month told its network hospitals in 34 states, including Florida, that it would assess hospitalization requests to determine whether the visits were indeed medical emergencies.

Claims that are not related to emergencies will not be subject to any coverage or limited coverage based on the patient’s insurance plan, depending on the insurer’s notice sent to hospitals. Up to 1 in 10 claims could be dismissed, said Tracey Lempner, spokesperson for the Minnesota-based insurer.

UnitedHealthcare’s policy affects commercially insured patients with employer-sponsored plans and does not apply to patients on Medicare Advantage or who have Medicaid coverage with UnitedHealthcare, Lempner said.

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UnitedHealthcare in 2018 said it had more than 30 million Americans with business or employer-sponsored plans.

“If it is determined that the event is not an emergency, the claim will be paid based on the member’s benefits,” Lempner said, adding, “We estimate that nationally, less than 10% complaints (from the emergency department) will be classified as non-emerging through this program.

The policy will go into effect in 34 states and the District of Columbia, Lempner said. They are: Alabama, Arizona, Arkansas, Colorado, Connecticut, Washington, DC, Delaware, Florida, Georgia, Indiana, Iowa, Kansas, Kentucky, Louisiana, Maryland, Massachusetts, Michigan, Mississippi, Nebraska, Nevada, New Hampshire, New Jersey , New York, Ohio, Oklahoma, Oregon, Pennsylvania, South Carolina, Tennessee, Texas, Utah, Virginia, Washington, West Virginia and Wisconsin.

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National groups oppose

The policy applies to the hospital portion of emergency room care, so patients could be billed when the request is denied, said Laura Wooster, associate executive director of public affairs for the physicians’ organization. emergency based in Washington, DC

“If United don’t cover it then the patient will be hooked,” she said. “Looks like they’re not about to pay the (emergency doctor’s bill). We are trying to get more information on this.

She couldn’t say if other insurers would adopt a similar policy.

“I’m sure they’ll keep an eye on it,” she said.

This isn’t the first time insurers have adopted policies to deny claims from emergency rooms, often the most expensive source of medical care.

Indianapolis-based Anthem adopted a similar policy in 2018, which is on trial by the Emergency Physician Panel, she said. And UnitedHealthcare in 2018 began reducing ER claims when it determined the coding was inappropriate.

The American Hospital Association is calling on UnitedHealthcare to immediately reverse the new policy, President and CEO Richard Pollack said in a June 8 letter to the insurer.

The insurer’s parent company, UnitedHealth Group, earned $ 6.7 billion in the first quarter of the year, according to the hospital association.

“Patients are not medical experts and should not expect to be self-diagnosing during what they believe to be a medical emergency,” Pollack said in his letter. “Threatening patients with a financial penalty for making the wrong decision could have a deterrent effect on seeking emergency care.

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“It is dangerous to the health of patients at all times, but it is particularly dangerous in the midst of a public health emergency,” he said, referring to the COVID-19 pandemic.

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

UnitedHealthcare defends its policy

Lempner said unnecessary use of emergency rooms costs $ 32 billion a year and increases healthcare costs for everyone.

“We are taking steps to make care more affordable, encouraging people who do not have a medical emergency to seek treatment in a more appropriate setting, such as an emergency care center,” she said. declared.

“If one of our members receives emergency room care for a non-urgent problem, such as pink eye, we will reimburse the emergency facility according to the member’s benefit plan,” he said. she declared.

In the Notice to Hospitals, UnitedHealthcare states that emergency department claims will be assessed based on the problem presented by the patient, the intensity of diagnostic services performed, and other patient complicating factors and external causes.

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When claims are denied, hospitals can present evidence that an emergency room visit meets the definition of an emergency that meets the layman’s prudent standard, in the opinion of the insurer.

The National Emergency Physicians Group believes the new policy is in direct violation of the federal layman standard, according to a June 8 statement on UnitedHealthcare’s new policy.

Federal policy requires insurance companies to provide emergency room care coverage based on the symptoms that brought the patient to the emergency room and not the final diagnosis, according to the group of doctors.

“While we are appalled by United’s move, we are sadly not surprised that an insurance company is once again trying to cut costs at the expense of necessary patient care,” said Dr Mark Rosenberg, chairman of the group of emergency physicians, said in a statement.

“UnitedHealthcare expects patients to self-diagnose a potential medical emergency before seeing a doctor, and then punish them financially if they are wrong,” Rosenberg said.

According to the Centers for Disease Control and Prevention, 3% of emergency room visits are not urgent, the group of emergency doctors said.

Dr. Leon L. Haley Jr., Certified Emergency Physician, CEO of UF Health Jacksonville and Dean of UF College of Medicine & # x002013;  Jacksonville, is among the first in Florida to be vaccinated on Monday.

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With 90% of symptoms overlapping between non-urgent and emerging conditions, in many cases even doctors can’t tell if a patient’s symptoms require emergency treatment without performing a full medical examination, said the group of doctors.

Lempner of UnitedHealthcare said the policy was in line with federal regulations and the layman’s standard.

UnitedHealthcare’s new policy is more damaging to patients than the one Anthem adopted in 2018 in many states, which has led the group of emergency physicians to take legal action against Anthem, which is still pending, said Wooster from the Doctors Group.

Anthem began denying payment for emergency services in a handful of states when the insurer decided the member was not facing an emergency. As a result, patients got stuck with the bills.

“They largely canceled it,” Wooster said. “They don’t apply it.”

This article originally appeared on Naples Daily News: UnitedHealthcare to assess emergency requests, stick patients with bills

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