Skip to main content

Provider Stakeholders to UnitedHealthcare: A Delay Isn't Enough

Analysis  |  By Alexandra Wilson Pecci  
   June 22, 2021

Nearly a week after UnitedHealthcare backed off its decision to retroactively deny emergency care claims, provider groups are still hitting back.

UnitedHealthcare has temporarily backed off its decision to retroactively deny emergency care claims, but that hasn't stopped the outcry from provider organizations.

On June 16, nearly a week after UnitedHealthcare announced that it would delay the change until at least the end of the COVID pandemic, a group of 32 provider and patient advocacy organizations penned a letter to UnitedHealthcare CEO Brian Thompson "to express deep concerns" about the plan.

The organizations—which include the American Medical Association, Emergency Nurses Association, America's Essential Hospitals, Association of American Medical Colleges, and the Federation of American Hospitals —wrote that a temporary delay wasn't enough.

"[W]e write to urge you to rescind these policies permanently, and to express our belief that there is a better way to ensure that patients access the right care, in the right place, at the right time," the letter said. "We invite you to work together with us on these efforts."

Their arguments against the policy change echoed those of other stakeholders by saying that patients don't have the knowledge needed to self-diagnose and that providers need to run tests to reach an accurate diagnosis.

They also cited additional data showing how symptoms of low-acuity and emergent conditions often overlap:

A 2013 JAMA study found that patients who receive a diagnosis of a low-acuity condition often present with initial complaints similar to patients with more serious conditions. Examining a dataset of over 34,900 unique emergency department (ED) visits found that 6.3% of visits were determined to have primary care–treatable diagnoses based on discharge diagnosis, yet the chief complaints reported for these ED visits were the same chief complaints reported for 88.7% of all ED visits. Of these visits, 11.1% were serious enough to be identified at ED triage as needing immediate emergency care, and 12.5% required hospital admission (with 3.4% of these going directly from the ED to the operating room).

The letter also states that UnitedHealthcare's plan to give providers whose claim is denied the chance to "complete an attestation if the event met the definition of an emergency consistent with the prudent layperson [PLP] standard" is flawed and would have a "chilling" effect on whether patients seek needed care.

"Although the new policy claims to take into account the PLP standard, it does so by including an attestation process after an initial claim is denied," the letter said. "A policy of 'deny first, attest later' is in itself a clear violation of the [prudent layperson] standard and will undoubtedly harm patients."

Of the delay, UnitedHealthcare told HealthLeaders in a statement, "We will use this time to continue to educate consumers, customers and providers on the new program and help ensure that people visit an appropriate site of service for non-emergency care needs." 

Here are five more things to know about the UnitedHealthcare news:

1. The original announcement

UnitedHealthcare used a network bulletin to say it would evaluate ED claims for several factors, including:

  • The patient's presenting problem
  • The intensity of diagnostic services performed
  • Other patient complicating factors and external causes

"Claims determined to be non-emergent will be subject to no coverage or limited coverage in accordance with the member's Certificate of Coverage," United Healthcare said in the bulleting.

Other health insurers have been criticized for similar policies, with emergency healthcare providers and others arguing that the threat of denied coverage and big bills could deter patients from seeking needed emergency care.

United Healthcare originally said this will apply to "commercial fully insured ED facility claims in many states for dates of service on July 1, 2021, or later. Subject to regulatory approval we will continue to expand this capability to additional states and segments."

2. The plan addressed the prudent layperson standard

UnitedHealthcare said that 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.

For instance, a patient presenting with severe chest pains that turn out to be an anxiety attack, rather than a cardiac event, should have their emergency care covered, according to the standard.

3. The blowback was swift

The American Hospital Association, the Federation of American Hospitals, and the American College of Emergency Physicians blasted UHC's decision to retroactive review claims.

Calling it a "dangerous decision" and a "scare tactic," the American College of Emergency Physicians (ACEP) condemned UnitedHealthcare's plan 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.

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 Rosenberg.

The American Hospital Association (AHA) joined 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 ThompsonRichard 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 well-being 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 also asked UnitedHealthcare to "confirm in writing that if the facility attests that a case met the prudent layperson standard that the services will be covered."

4. UnitedHealthcare has backed off—temporarily

 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, we have decided to delay the implementation of our emergency department program until at least the end of the national public health emergency period," UHC said in a statement provided to HealthLeaders. 

5. Avoiding care is common

In its letter, the 32 healthcare groups writing to UnitedHealthcare pointed out that patients already avoid or don't get the care they need.

For instance, they pointed to the need for mental healthcare and substance use services, which was "reaching crisis levels" even pre-pandemic.

"In 2019, less than half of adults with mental health conditions received services, and nearly 90% of those with a substance use disorder did not receive treatment. EDs around the country often serve as the only safety net for a fragmented mental health infrastructure," they wrote. "For those in crisis for whom the ED is a lifeline for care, an added threat of a retroactive denial of coverage under this policy can be devastating."

In addition, two recent surveys showed that avoiding care because of cost is common.

One survey, the Patientco 2021 State of the Patient Financial Experience Report, found that nearly one-third of patients say they've avoided care because they were worried about what they would owe.

Another survey, the 2021 VisitPay Report, showed that 35% of patients said they would put off COVID-19 treatment to avoid medical bills, and more than one-third said they're more worried about the financial burdens associated with COVID-19 than actually becoming sick.

Alexandra Wilson Pecci is an editor for HealthLeaders.

Get the latest on healthcare leadership in your inbox.