AHA asks UnitedHealthcare to reverse ED claims policy


Numerous healthcare providers and policymakers are publicly speaking out against UnitedHealthcare’s new policy of retroactively denying patients’ emergency care claims that are considered non-emergent.

In a letter to UnitedHealthcare on Wednesday, the American Hospital Association said it is “deeply concerned” about the policy’s potential effect on patients’ access to care and health outcomes.

“Patients are not medical experts and should not be expected to self-diagnose during what they believe is a medical emergency,” the letter said. “Threatening patients with a financial penalty for making the wrong decision could have a chilling effect on seeking emergency care.”

Opponents of the policy argue it is illegal under the prudent layperson standard—which requires insurers to cover emergency department visits based on a patient’s symptoms coming in, instead of their final diagnosis—and could scare people off from receiving necessary treatment.

UnitedHealthcare said it will still cover the costs for ED visits if fully insured commercial members have a presenting problem, such as chest pain, shortness of breath, dizziness or mental confusion, that is considered to be an emergency.

It said conditions will be examined in addition to diagnostic services and other complicating factors and external causes like diabetes or cancer to determine if the presenting problem will be covered.

While the insurer said it wants members to go to the ED, and is still covering ED visits, it intends to deter people who are “chronically using the emergency room for non-emergent or minor conditions.”

So, UnitedHealthcare is also encouraging members to use its digital tools to help check symptoms and connect to appropriate network care options or seek a telehealth appointment with a primary care physician if they are not experiencing an emergency situation.

Molly Smith, group vice president for public policy at AHA, said this policy causes friction and confusion for patients, and could lead to “real consequences” such as excess deaths due to emergency service avoidance.

“It’s really dangerous to create any question in people’s mind about whether they think they’re experiencing an emergency [or] whether or not they should really access emergency services,” Smith said.

Over the past year, UnitedHealthcare has been implementing site of service policies that reduce access to hospital outpatient departments, meaning patients have less options to turn to for care, according to Smith.

Ryan Stanton, emergency physician and board of directors member at the American College of Physicians, said the policy will not save costs as emergency physicians are still obligated to provide care, including a medical screening exam which contributes to a lion’s share of the cost and resources.

“All it is, is another attempt to shift costs to the patients, potentially putting them at risk for financial ruination,” Stanton said.

UnitedHealthcare said going to an ED for care in a non-emergency situation can cost its members up to nine times more when compared to urgent care and 35 times more than a virtual appointment.

It added that if a patient’s claim is classified as a non-emergency, healthcare professionals at the facility where the patient was treated are able to attest that the care given was for an emergency.

Stanton said UnitedHealthcare’s new policy is purposely vague with the types of ED visit claims it will deny, although it would not make much of a difference to deny claims for minor conditions.

“They’re only going to save money and have a significant impact on their bottom line if they deny high cost evaluations which are those challenging abdominal pains and chest pains and headaches and neurologic symptoms and things that can be true emergencies,” Stanton said. “But we don’t know that until we get the evaluation done.”