News: UnitedHealthcare to assess ED claims, potentially deny those deemed ‘non-emergent’

Editor's note: After this article was published on the morning of June 10, 2021, UnitedHealthcare announced they would be delaying the policy based on provider feedback. Stay tuned to CDI Strategies next week for more information about the delay.

UnitedHealthcare plans to start assessing emergency department (ED) commercial claims and possibly denying those that it deems non-emergent starting on July 1, according to a recently released network bulletin. The payer says they will start with select states and then expand as they are able, subject to regulatory approval.

The company said it’ll evaluate 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,” UnitedHealthcare said in the bulletin.

UnitedHealthcare also said that 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 example, 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.

Other 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, according to HealthLeaders.

This fear was borne out in two recently published surveys that suggest avoiding care due to cost is common. First, 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, HealthLeaders reported. Secondly, 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.

Editor’s note: This article originally appeared in HealthLeaders. To read a recent story about UnitedHealthcare’s plans to use Sepsis-3 criteria for pre-payment reviews, click here.