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UnitedHealthcare delays plan to deny ER coverage for certain visits

The new policy would provide limited or no coverage for emergency room visits that are deemed nonurgent.

MINNETONKA, Minn. — After hearing opposition from numerous healthcare organizations, UnitedHealthcare is delaying a policy change that would provide limited or no coverage for emergency room visits that are deemed nonurgent, the company announced Thursday.

Days prior, UnitedHealthcare, the nation’s largest health insurer, announced it would change its ER policy in 37 states starting July 1 in an effort to encourage patients to seek urgent care, doctor office visits or virtual visits when appropriate. The company said it would still fully cover visits deemed actual emergencies according to each patient’s plan.

Minnesota is not included in the policy change.

The announcement led to widespread backlash from medical and hospital groups concerned the new policy would lead to patients avoiding care or facing financial penalties for seeking emergency care. A UnitedHealthcare spokesperson said the company heard the feedback, considered, and ultimately decided to delay the policy change.

“… based on feedback from our provider partners and discussions with medical societies, we have decided to delay the implementation of our emergency department policy until at least the end of the national public health emergency period,” said UnitedHealthcare spokesperson Tracey Lempner in an emailed statement to KARE-11. “We will use this time to continue to educate consumers, customers and providers on the new policy and help ensure that people visit an appropriate site of service for non-emergency care needs.”

Many doctors and hospital groups objected to the policy change, citing concerns over patient wellbeing.

“We object to UnitedHealthcare’s pending policy that asks patients to second guess their instincts that emergency care is needed,” said Dr. Susan R. Bailey, president of the American Medical Association. “Patients should not be expected to self-diagnose to determine whether, for example, chest pain is a heart attack or indigestion.”

Nationally, emergency department visits were down 27% last year over 2019, according to a report from GIST Healthcare.

According to a UnitedHealthcare report from 2019, the insurer says two-thirds of emergency room visits – that’s 18 million out of 27 million – were avoidable. The report says these 18 million annual unnecessary visits to the ER add $32 billion in costs to the health care system each year.

UHC contends the cost of hospital ER visits are 12 times higher than a doctor’s office visit, and 10 times higher than an urgent care visit.

UnitedHealthcare says the policy change will take effect when the public health emergency expires.

July 15th, the national public health emergency will expire, unless the Secretary of the Department of Health and Human Services renews it another 90 days.

How UnitedHealthcare expects patients to know what is and is not an actual emergency before care remains unclear, but a spokesperson for the company says emergency visit claims will be evaluated in three steps.

First, what is the presenting problem the patient has, i.e. chest pain. Second, what amount of services did the patient use to diagnose the condition. Third, were there any complicating factors the patient had, such as diabetes.

In the case of chest pain, the United spokesperson said even if it turned out to be heartburn, that patient would receive coverage for the visit.  

If the reason for the visit is something like pink eye, the spokesperson said that visit would not be covered as the patient could have used a different setting for care.

The policy change only applies to fully insured employer group plans.