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UHC Backs Off Retroactive Review of Emergency Care Claims, For Now

Analysis  |  By John Commins  
   June 10, 2021

Providers are urging UHC for a "full and permanent reversal" of the policy.

UnitedHealthcare has temporarily shelved its decision to retroactively deny emergency care claims after acknowledging withering blowback from major provider associations.

The American Hospital Association, the Federation of American Hospitals, and the American College of Emergency Physicians had blasted UHC's decision to retroactive review claims. The policy was supposed to take effect next month, but UHC said it would delay implementation until at least the end of the COVID-19 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," UHC said in a statement.

In a letter to UHC's CEO Brian Thompson, urging him to reverse the decision, AHA President and CEO Richard J. Pollack said "patients are not medical experts and should not be expected to self-diagnose during what they believe is a medical emergency."

"Threatening patients with a financial penalty for making the wrong decision could have a chilling effect on seeking emergency care," Pollack said.

Pollack issued a statement after UHC announced the delay. He applauded the "temporary reprieve for patients" and pressed UHC for a "full and permanent reversal."

"If enacted, this policy would have a chilling effect on patients seeking emergency services, with potentially dire consequences for their health," Pollack said, adding that the policy "is also part of an unfortunate pattern of commercial health insurers denying care for needed services."

"Patients should have the confidence to seek the emergency care they need without worrying about coverage being denied," he said. "There is no justification for these restrictions now or after the public health emergency."

Like ACEP, the AHA points to the "prudent layperson standard," which requires health insurance plans to base reimbursement on a patient's presenting complaint rather than the final diagnosis, according to the American Academy of Emergency Medicine.

AHA is also asking United Healthcare to "confirm in writing that if the facility attests that a case met the prudent layperson standard that the services will be covered."

AHA says United Healthcare "acknowledges that this policy change is financially-motivated" and is skeptical of United Healthcare's argument that it would pass those cost savings onto consumers.

It says United Healthcare premiums and profits continue to rise even as it restricts coverage, noting that United Healthcare's parent company UnitedHealth Group posted a 35% year-over-year increase in operating profits in the first quarter of 2021.

"Despite earning $6.7 billion in a single quarter, UHC enrollees are being asked to pay more for their coverage," Pollack writes.

In addition to calling on United Healthcare to reverse its policy, the AHA also questions some of United Healthcare's other policies and guidance that appear to contradict its plan to retroactively deny emergency care claims.

For instance:

AHA cites United Healthcare's own online guidance for its members to that seems to contradict the new policy, which says: "Do not ignore an emergency. Take action if a situation seems life-threatening. Head to your nearest emergency room or call 9-1-1 or your local emergency number right away."

AHA says the new policy "raises significant questions about the criteria UHC will use to determine emergency services coverage."

AHA questions how United Healthcare is addressing the kinds of healthcare barriers that might push patients toward emergency care, such whether its enrollees have enough providers available during non-traditional hours; whether they help connect their enrollees with a primary care provider; whether its networks offer sufficient access to alternate sites of care, and whether it will cover the care provided at those sites without excessive administrative barriers.

AHA suggests other United Healthcare policies also restrict access—and therefore push patients to emergency departments even more. For instance, AHA cites a policy 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."

HealthLeaders' Alexandra Wilson Pecci contributed to this report.

“Despite earning $6.7 billion in a single quarter, UHC enrollees are being asked to pay more for their coverage.”

John Commins is a content specialist and online news editor for HealthLeaders, a Simplify Compliance brand.

Photo credit: Los Angeles, California, USA - 21 Jule 2019: Illustrative Editorial of UHC.COM website homepage. UNITEDHEALTHCARE logo visible on display screen. By II.studio / Shutterstock


KEY TAKEAWAYS

The policy was supposed to take effect next month, but UHC said it would delay implementation until at least the end of the COVID-19 pandemic.

Providers say payers should abide by the "prudent layperson standard," which requires payers to base reimbursement on a patient's presenting complaint rather than the final diagnosis.


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