Amid mounting criticism from hospitals and physician groups, health insurance giant UnitedHealthcare has said it will delay a policy that looks at payments for non-emergency emergency room visits.
The policy to review and possibly restrict certain hospital payments has sparked protests from the American Hospital Association and the American College of Emergency Physicians over the potential damage to the health and finances of patients.
In a statement released Thursday, the Minnesota-based insurer said police would be on hold until the pandemic is over.
“Based on feedback from our supplier partners and discussions with medical companies, we have decided to delay the implementation of our emergency service policy until at least the end of the national emergency period of public health, ”Tracey Lempner, spokesperson for the Minnesota-based insurer. , said in a statement.
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American Hospital Association officials have urged the insurer to drop the policy altogether. If passed, the policy “would have a chilling effect on patients seeking emergency services, with potentially disastrous consequences for their health,” said Rick Pollack, president and CEO of the hospital group.
Likewise, the American College of Emergency Physicians said it was concerned the change would prevent patients from using emergency rooms because they would be responsible for their hospital bills when UnitedHealthcare rejects them.
UnitedHealthcare told its network hospitals in 34 states this month that it will assess emergency service requests to determine whether the visits are indeed medical emergencies.
Under the now-delayed policy, claims that are not related to emergencies would not be subject to any coverage or limited coverage based on the patient’s insurance plan, according to the insurer’s notice sent to hospitals. . Up to 1 in 10 claims could be dismissed, said Lempner, spokesperson for Minnesota-based insurer
UnitedHealthcare’s policy affects commercially insured patients with employer-sponsored plans and does not apply to patients on Medicare Advantage or who have Medicaid coverage with UnitedHealthcare, Lempner said.
Experts say health insurers frequently argue over payment policies with hospitals and emergency care providers due to the rising cost of medical care. Hospitals have higher overhead costs and generally charge more for similar procedures compared to outpatient care, said Benedic Ippolito, American Enterprise Institute resident researcher and health economist.
Insurers “have a great incentive to try and direct people to the most profitable healthcare sites,” Ippolito said. “In concept, the idea is solid … Whether this is the right way to do it is a separate question.”
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Lempner said unnecessary use of emergency rooms costs $ 32 billion a year and increases healthcare costs for everyone.
“We are taking steps to make care more affordable, encouraging people who do not have a medical emergency to seek treatment in a more appropriate setting, such as an emergency care center,” she said. declared.
“If one of our members receives emergency room care for a non-urgent problem, such as pink eye, we will reimburse the emergency facility according to the member’s benefit plan. “
In the notice to hospitals announcing the now delayed policy, UnitedHealthcare says emergency department claims will be assessed based on the problem presented by the patient, the intensity of diagnostic services performed and other patient complicating factors and causes. external.
When claims are denied, hospitals can present evidence that an emergency room visit meets the definition of an emergency that meets the layman’s prudent standard, in the opinion of the insurer.
The National Emergency Physicians Group believes the delayed policy is in direct violation of the federal lay standard, according to a June 8 statement on UnitedHealthcare’s new policy.
Federal policy requires insurance companies to provide emergency room care coverage based on the symptoms that brought the patient to the emergency room and not the final diagnosis, according to the group of doctors.
“While we are appalled by United’s move, we are sadly not surprised to see an insurance company once again attempting to cut costs at the expense of necessary patient care,” said Dr Mark Rosenberg, chairman of the group of emergency physicians, said in a statement.
“UnitedHealthcare expects patients to self-diagnose a potential medical emergency before seeing a doctor, and then punish them financially if they are wrong,” Rosenberg said.
According to the Centers for Disease Control and Prevention, 3% of emergency room visits are not urgent, the group of emergency doctors said.
With 90% of symptoms overlapping between non-urgent and emerging conditions, in many cases even doctors can’t tell if a patient’s symptoms require emergency treatment without performing a full medical examination, said the group of doctors.
Lempner of UnitedHealthcare said the policy was in line with federal regulations and the layman’s standard.
UnitedHealthcare’s new policy is more damaging to patients than the one Anthem adopted in 2018 in many states, which has led the group of emergency physicians to take legal action against Anthem, which is still pending, said Wooster from the Doctors Group.
Anthem began denying payment for emergency services in a handful of states when the insurer decided the member was not facing an emergency. As a result, patients got stuck with the bills.
“They largely canceled it,” Wooster said. “They don’t apply it.”