The American Hospital Association (AHA) is urging UnitedHealthcare to roll back a newly unveiled policy that could lead the insurer to retroactively reject emergency department claims.
UnitedHealth released a provider brief late last week on the policy, under which the country's largest commercial payer said it will evaluate ED claims and retroactively deny those it deems nonemergent.
The insurer said it will evaluate claims denials based on a number of criteria, including the reason the patient presented to the ED, the severity of testing used by providers and any comorbidities the patient may have.
In a letter to UnitedHealthcare CEO Brian Thompson, the AHA says the new policy would "put patients’ health and wellbeing in jeopardy."
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"Patients are not medical experts and should not be expected to self-diagnose during what they believe is a medical emergency," AHA President Rick Pollack wrote. "Threatening patients with a financial penalty for making the wrong decision could have a chilling effect on seeking emergency care."
If an emergency room visit is ruled nonemergent, the hospital can submit an attestation to UnitedHealthcare within a set window to contest that determination. If the attestation is submitted on time, the insurer will cover the visit under the patient's emergency care benefit, UnitedHealth said.
The goal of the policy, UnitedHealthcare said, is to cut down on the high costs associated with unnecessary emergency care. UHC said unnecessary ER use costs $32 billion per year.
In the letter, the AHA says the insurer should evaluate whether its own coverage policies for hospital outpatient care may push more people to go to the ER instead.
"For example, UHC has announced policies 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," Pollack wrote. "If UHC is successful in denying coverage for these services in hospital outpatient departments, it could exacerbate UHC’s concerns regarding emergency department use."
The American College of Emergency Physicians has also pushed back on UnitedHealthcare's policy.