UnitedHealthcare to crack down on ER visits, potentially exposing patients to bigger bills


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Dive Brief:

  • The nation’s largest commercial insurer is taking a closer look at whether visits to the emergency room by some of its members are necessary. Starting July 1, UnitedHealthcare will evaluate ER claims using a number of factors to determine if the visit was truly an emergency for its fully insured commercial members across many states, according to a provider bulletin
  • If UnitedHealthcare finds the visit was a non-emergency, the visit will be “subject to no coverage or limited coverage,” the provider alert states.
  • However, a statement provided to Healthcare Dive said the insurer will reimburse for non-emergency care according to the member’s benefit plan. In other words, the amount paid by UnitedHealthcare may be less if deemed a non-emergency.    

Dive Insight:

Patients seeking out the pricey ER setting for minor illnesses that could have been treated elsewhere has been a perennial issue for the healthcare industry. Misuse of the nation’s emergency departments for minor ailments costs the nation’s healthcare system $32 billion a year, according to a previous report from UnitedHealth Group, the parent firm of UnitedHealthcare.

Providers worry such policies will lead to a chilling effect, causing patients to hesitate even in a true emergency such as a heart attack or stroke. Some of those concerns about the effects on patients were aired on Twitter this week after the provider bulletin became public. 

UnitedHealthcare’s policy contains exclusions, including observation stays, visits by children under the age of two and admissions from the ER.  It’s not clear precisely how many patients will be impacted but UnitedHealthcare had a total of 26.2 million commercial members at the end of 2020.

The insurer said this is an attempt to ensure healthcare is more affordable. To curb costs, they want patients to seek out treatment in a more “appropriate setting” like an urgent care facility. 

Other major insurers have enacted similar policies in the past and faced pushback from the public and providers.

Anthem in recent years has also enacted policies that put patients on the hook for the ER bill if they sought care that didn’t warrant a trip to the ER. The policy also attracted scrutiny from then Senator Claire McCaskill, a Missouri Democrat, who requested Anthem turn over internal documents over the policy and the Blues player ultimately scaled back some of its policies amid pushback from doctors and others.

Providers have argued these policies collide with federal law that require emergency rooms to treat any patient that shows up, regardless of their ability to pay.

UnitedHealthcare does have a process in place for those to contest a visit that was deemed a non-emergency.

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