It also comes at a time when providers continue to face the loss of ER visits, which have remained depressed during the COVID-19 pandemic, even as other volumes recover. But many provider groups, including the American Hospital Association and the American College of Emergency Physicians, came out publicly against the policy change, arguing it would jeopardize patient’s physical and financial health and could actually be illegal under the prudent layperson standard. AHA and ACEP said the policy could result in patients avoiding the ER, worried about unexpected medical bills.
That could potentially leave patients on the hook for some of the most expensive medical bills in American healthcare today. Earlier this month, insurance giant UnitedHealthcare informed its hospital networks it would be retroactively assessing ER claims to determine if the visit was medically necessary, beginning July 1. If the claim is determined to be non-emergent, such as a visit for pink eye, it would be subject to limited or no coverage based on a patient’s specific insurance plan.
In the notice to hospitals, UnitedHealthcare said claims would be assessed based on a patient’s presenting problem, the acuity of services performed and other complicating factors. There would have been a process in place for providers to contest the claim denial, by submitting evidence to UnitedHealthcare that the visit met the prudent layperson standard, a federal policy requiring payers to cover ER care based on presenting symptoms and not the final diagnosis. Dive Insight:
Prior to Thursday’s delay, the new policy would have applied to UnitedHealthcare’s commercially insured patients in employer-sponsored plans. Currently, the payer has more than 26 million commercial members. Patients covered by Medicare Advantage or in contracted Medicaid plans would have been unaffected. It’s not the first time payers have targeted stemming ER claims as a way to drive down medical costs. Indianapolis-based Anthem adopted a similar policy in 2018, but ultimately scaled the changes back after the move attracted ire from legislators and doctors.
Patients turning to the pricey ER setting for minor health needs is long-standing problem in healthcare. Though only about 6% of ER visits annually are actually nonemergent, misuse of emergency departments for minor ailments costs the nation’s healthcare system $32 billion a year, according to a previous report from UnitedHealth. “Patients are not medical experts and should not be expected to self-diagnose during what they believe is a medical emergency,” AHA CEO Rick Pollack wrote in a letter to UnitedHealthcare. “Threatening patients with a financial penalty for making the wrong decision could have a chilling effect on seeking emergency care.”
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