UnitedHealthcare may retroactively reject 'non-emergent' ER claims under new coverage policy

A newly released UnitedHealthcare policy on coverage for emergency care is likely to draw significant ire from providers.

The policy, issued in a provider brief posted late last week, would extend no coverage or limited coverage to emergency department claims the insurer retroactively deems non-emergent. The change will take effect July 1 in fully insured commercial plans in "many states."

UnitedHealthcare said in the brief that it is aiming to extend the policy to other business segments pending regulatory approvals.

The insurer said decisions will be based on multiple criteria: the initial concerns that led the patient to present at the ED, the intensity of diagnostic services provided and other complicating factors such as chronic conditions a patient may have.

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"Unnecessary use of the emergency room costs nearly $32 billion annually, driving up healthcare costs for everyone. We are taking steps to make care more affordable, encouraging people who do not have a healthcare emergency to seek treatment in a more appropriate setting, such as an urgent care center," UnitedHealthcare said in a statement to Fierce Healthcare.

"If one of our members does receive care in an emergency room for a non-emergent issue, like pink eye, we will reimburse the emergency facility according to the member's benefit plan," the insurer said.

For claims that are rejected, providers can submit an attestation to challenge the decision, UnitedHealthcare said. The insurer will send out a notice of attestation once an emergency department visit is deemed non-emergent, and, if the attestation is submitted within the requested time frame, UnitedHealth will cover the visit under the member's emergency care benefit.

UnitedHealthcare said the attestation should be completed by healthcare professionals such as the attending physician, medical director of the ED or nursing director of the ED. If the attestation is not submitted, the visit will be covered with little or no coverage, based on the member's plan. Members can appeal the decision, UnitedHealthcare said.

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The policy is set to rankle emergency care providers who decried a similar policy from Anthem rolled out in 2017. The American College of Emergency Physicians (ACEP) sued the insurer for retroactively denying coverage for emergency visits it determined were not emergencies.

Providers warned then that policies like this could encourage patients to avoid care altogether in potential emergency situations and that they violate the "prudent layperson" legal standard, which aims to discourage insurers from determining what constitutes an emergency. 

ACEP said in a statement to Fierce Healthcare that it sees UnitedHealthcare's policy as similarly in violation of the standard.

"According to the Centers for Disease Control and Prevention, only 3% of emergency visits are 'nonurgent,'" ACEP said. "In many instances, even physicians do not know if a patient’s symptoms require emergency treatment without undergoing medical examination and tests. Our main concern is that dangerous policies such as this will leave millions fearful of seeking medical care, right as we’re just getting hold of the COVID-19 pandemic and trying to get as many people vaccinated as possible."

Seth Trueger, M.D., an emergency physician at Northwestern Emergency Medicine and the digital media editor for JAMA Network Open, said in a tweet that UnitedHealth's policy is "a garbage policy that will throw babies out with the bathwater."

"Regardless, the goal here is chilling, so people second-guess whether to seek care for their symptoms, which is the whole spirit of the prudent layperson standard," Trueger wrote.