Emergency Physicians Call United Healthcare's ED Denial Policy 'Dangerous'

The American College of Emergency Physicians said that it "firmly believes that the new policy is in direct violation of the federal Prudent Layperson Standard."

Calling it a "dangerous decision" and a "scare tactic," the American College of Emergency Physicians (ACEP) is condemning UnitedHealthcare's recent announcement to retroactively deny emergency care claims.

"ACEP firmly believes that the new policy is in direct violation of the federal Prudent Layperson Standard, which requires insurance companies to provide coverage of emergency care based on the presenting symptoms that brought the patient to the emergency department, not the final diagnosis," ACEP said in a statement about the new policy.

This month, United Healthcare said that as of July 1, it'll start assessing ED facility commercial claims and possibly denying those that it deems non-emergent.

United Healthcare also says if it did find that an event was non-emergent, providers would have the chance to "complete an attestation if the event met the definition of an emergency consistent with the prudent layperson standard."

The "prudent layperson standard" 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.

ACEP says the prudent layperson standard exists for a reason. It notes that since 90% of symptoms overlap between nonurgent and emergent conditions, even physicians often can't tell whether a patient's symptoms require emergency treatment without conducting a comprehensive medical examination.

ACEP also says few emergency visits are "nonurgent."

"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," Mark Rosenberg, DO, MBA, FACEP, president of ACEP, 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."

ACEP also points out that thanks to COVID-19, the past year has illustrated "the devastating impact of when patients avoid treatment—including worsening health conditions and even death."

"This new policy will leave millions fearful of seeking medical care, just as we're getting hold of the COVID-19 pandemic and trying to get as many people vaccinated as possible," said Dr. Rosenberg.

Avoiding care because of cost is common, according to two surveys out last week, one from Patientco and the other from VisitPay.