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UnitedHealthcare to Toughen Emergency Claim Scrutiny

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What You Need to Know

  • UnitedHealthcare says it might review a patient's records, even if the provider attests that a visit was justified under the prudent layperson standard.
  • ACEP, a group for emergency physicians, questions whether the insurer's new approach will meet the prudent layperson standard.
  • ACEP says COVID-19-related fear of getting necessary emergency care is a bigger problem right now than over-use of emergency care.

The health insurance arm of UnitedHealth Group Inc. says it will be more strict about covering hospital emergency room claims starting July 1.

The insurance company unit, UnitedHealthcare, announced earlier this week, in a bulletin aimed at doctors and hospital administrators, that it has improved its ability to determine whether a patient’s visit to an emergency room was really related to a true emergency, according to the provisions of commercial health insurance plans.

UnitedHealthcare’s coverage rules are important, because the Minnetonka, Minnesota-based company provides or administers coverage for 49 million people, or about 15% of all people.

The company says it will evaluate whether emergency room claims are related to true emergencies based on:

  • The patient’s presenting problem.
  • The intensity of diagnostic services performed.
  • Other patient complicating factors and external causes.
  • Whether the provider attests that the visit is for an event that meets the federal “prudent layperson” standard, meaning that the visit was for symptoms, such as chest pain, that would strike a prudent layperson as a reason to seek emergency care.

“Claims determined to be non-emergent will be subject to no coverage or limited coverage in accordance with the member’s Certificate of Coverage,” the insurer says in the bulletin. “This enhanced capability will apply to commercial fully insured [emergency department (ED)] facility claims in many states for dates of service on July 1, 2021, or later. Subject to regulatory approval we will continue to expand this capability to additional states and segments.”

Providers’ Reaction

The American College of Emergency Physicians, a group for 40,000 emergency room doctors, asserted in a response to the UnitedHealthcare announcement that only 3% of emergency visits are for nonurgent conditions.

ACEP questioned whether UnitedHealthcare’s approach will meet the federal prudential layperson standard.

“UnitedHealthcare is expecting patients to self-diagnose a potential medical emergency before seeing a physician, and then punishing them financially if they are incorrect,” Dr. Mark Rosenberg, ACEP’s president, said. in a comment included in ACEP’s response.

Today, in the wake of the COVID-19 pandemic, patients’ reluctance to get necessary emergency care is a bigger problem than unnecessary use of emergency care, he said.

“Over the past year, we’ve seen the devastating impact of when patients avoid treatment—including worsening health conditions and even death,” Rosenberg said.

(Photo: hxdbzxy/Shutterstock)


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