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AHA Blasts UnitedHealthcare's Plan to Retroactively Deny Emergency Claims

Analysis  |  By Alexandra Wilson Pecci  
   June 10, 2021

"Patients are not medical experts and should not be expected to self-diagnose during what they believe is a medical emergency," writes Richard J. Pollack, president and CEO of AHA.

The American Hospital Association (AHA) is joining the American College of Emergency Physicians to urge UnitedHealthcare to reverse its decision to retroactively deny emergency care claims.

In a letter to United Healthcare's CEO Brian Thompson, Richard J. Pollack, president and CEO of AHA, writes that hospitals and health systems are "deeply concerned" about the new policy, saying it would put patients' health and wellbeing in jeopardy.

"Patients are not medical experts and should not be expected to self-diagnose during what they believe is a medical emergency," Pollack writes. "Threatening patients with a financial penalty for making the wrong decision could have a chilling effect on seeking emergency care."

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."

Alexandra Wilson Pecci is an editor for HealthLeaders.


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