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United Healthcare Will Deny or Limit Coverage for ED Commercial Claims it Considers Non-Emergent

Analysis  |  By Alexandra Wilson Pecci  
   June 04, 2021

The new policy will apply to "commercial fully insured ED facility claims in many states for dates of service on July 1, 2021, or later."

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

In a network bulletin, United Healthcare said it'll 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.

Continue Reading:  If Anthem's Policy Spreads, 1 in 6 ER Visits Could Be Denied Coverage

United Healthcare said this it 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."

The payer 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.

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.

Avoiding care because of cost is common, according to two surveys out this week.

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, 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.


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