UnitedHealthcare to Crack Down on 'Non-Emergent' ED Claims

UnitedHealthcare plans to take a closer look at emergency department (ED) claims beginning July 1.

In a June network bulletin posted to its website, the insurer said that it will assess ED facility commercial claims to determine if an event was emergent or non-emergent. Claims determined to be non-emergent will be subject to no coverage or limited coverage.

ED claims will be evaluated on many factors, UnitedHealthcare said, including the patient's presenting problem, the intensity of the diagnostic services performed, and other patient complicating factors.

"Unnecessary use of the emergency room costs nearly $32 billion annually, driving up health care costs for everyone," UnitedHealthcare said in a statement provided to MedPage Today. "We are taking steps to make care more affordable, encouraging people who do not have a health care emergency to seek treatment in a more appropriate setting, such as an urgent care center. If one of our members does receive care in an emergency room for a non-emergent issue, like pink eye, we will reimburse the emergency facility according to the member's benefit plan."

Aside from urgent care centers, members can also seek treatment for non-emergent issues through their primary care physician or telemedicine.

When an ED event is deemed non-emergent, there will be an opportunity to complete an attestation if the event met the definition of an emergency consistent with the prudent layperson standard, UnitedHealthcare said in its posted bulletin. A notice of the opportunity to submit an attestation will be sent to the ED facility that provided the care.

Those who are able to fill out out an attestation saying an event was emergent include the attending physician, as well as medical and nursing directors. If an attestation is not filled out, members will have the option to file an appeal.

Concern over UnitedHealthcare's move has been making the rounds in the emergency physician community.

In a statement provided to MedPage Today, the American College of Emergency Physicians (ACEP) said that it believes the insurer's new policy is in "direct violation" of the federal prudent layperson standard. The standard, they noted, requires insurers to provide coverage of emergency care based on a patient's presenting symptoms that brought them to the ED.

"According to the CDC, only 3% of emergency visits are 'non-urgent,'" ACEP said. "In many instances, even physicians do not know if a patient's symptoms require emergency treatment without undergoing medical examination and tests. Our main concern is that dangerous policies such as this will leave millions fearful of seeking medical care, right as we're just getting hold of the COVID-19 pandemic and trying to get as many people vaccinated as possible."

UnitedHealthcare said that its new action will apply to commercial fully insured ED facility claims in many states for dates of service on July 1 or later. It added that it plans to expand the capability to additional states and segments, subject to regulatory approval.

The insurer did not immediately provide figures for its volume of non-emergent claims or their financial impact on its business.

UnitedHealthcare saw revenues of $55.1 billion in the first quarter of the year, up about 8% from the same quarter in 2020. Operating earnings were $4.1 billion for the first 3 months of 2021, compared with $2.9 billion for the same period last year.

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