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'Chilling effect on patients': Following backlash, insurance giant UnitedHealthcare delays policy to scrutinize ER claims


Ken AlltuckerLiz Freeman   | USA TODAY
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Facing mounting criticism from hospitals and doctors groups, health insurance giant UnitedHealthcare said it will delay a policy that would scrutinize payments for non-urgent emergency room visits.

The policy to review and potentially clamp down on some hospital payments drew outcries from the American Hospital Association and the American College of Emergency Physicians about potential harm of patients' health and finances.

In a Thursday statement, the Minnesota-based insurer said the policy will be halted until the end of the pandemic.

"Based on feedback from our provider partners and discussions with medical societies, we have decided to delay the implementation of our emergency department policy until at least the end of the national public health emergency period," Tracey Lempner, spokeswoman for the Minnesota-based insurer, said in a statement.

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American Hospital Association officials urged the insurer to abandon the policy altogether. If enacted, the policy "would have a chilling effect on patients seeking emergency services, with potentially dire consequences for their health," said Rick Pollack, president and CEO of the hospital group. 

Similarly, the American College of Emergency Physicians said it feared the change would cause patients to avoid 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 that it will assess emergency room claims to determine if visits were indeed medical emergencies.

Under the now-delayed policy, claims that are determined not to be tied to emergencies would be subject to no coverage or limited coverage based on the patient’s insurance plan, according to the insurer’s notice sent to hospitals. As many as 1 in 10 claims could be rejected, said Lempner, spokeswoman for the Minnesota-based insurer

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

Experts say health insurers frequently clash on payment policies with hospitals and emergency-care providers over the rising cost of medical care. Hospitals have higher overhead costs and typically charge more for similar procedures when compared to outpatient settings, said Benedic Ippolito, an American Enterprise Institute resident scholar and health economist.

Insurers "have a big incentive to try and steer people to the most cost-effective sites of care," Ippolito said. "In concept, the idea is sound … Whether this is the right way precisely to do it is a separate question."

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Lempner said unnecessary use of emergency rooms cost $32 billion annually and drives up health care costs for everyone.

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

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

In the notice to hospitals announcing the now-delayed policy, UnitedHealthcare says emergency room claims will be evaluated based on the patient’s presenting problem, the intensity of diagnostic services performed and other patient complicating factors and external causes.

When claims are denied, hospitals can submit evidence an emergency room visit met the definition of an emergency that is consistent with the prudent layperson standard, according to the insurer notice.

The national emergency physicians group believes the delayed policy is in direct violation of the federal layperson standard, according to a June 8 statement about UnitedHealthcare’s new policy.

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

“While we’re dismayed by United’s decision, we are not, unfortunately, surprised to see an insurance company once again try to cut its costs at the expense of necessary patient care,” Dr. Mark Rosenberg, president of the emergency physicians group, said in a statement.

“UnitedHealthcare is expecting patients to self-diagnose a potential medical emergency before seeing a physician, and then punishing them financially if they are incorrect,” Rosenberg said.

According to the Centers for Disease Control and Prevention, 3% of emergency room visits are non-urgent, the emergency physicians group said.

With 90% of symptoms overlapping between non-urgent and emergent conditions, in many instances even physicians cannot know if a patient’s symptoms require emergency treatment without conducting a comprehensive medical examination, the physicians group said.

UnitedHealthcare’s Lempner said the policy complies with federal regulations and the layperson standard.

UnitedHealthcare’s new policy is more detrimental to patients than the one adopted by Anthem in 2018 in many states that led the emergency physicians group to file the lawsuit against Anthem that is still pending, said Wooster of the physicians group.

Anthem began denying payment for emergency room services in a handful of states when the insurer decided the member did not face an emergency. As a result, patients were getting stuck with the bills.

“They have largely rolled it back,” Wooster said. “They are not enforcing it."

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