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Largest health insurance company plans to deny ER bills if it doubts you have had an emergency

Multi-value glass and brick building with UnitedHealthcare logo on the outside.
Enlarge / UnitedHealth Group Inc. is headquartered in Minnetonka, Minnesota, USA, on Wednesday, March 9, 2016.

Doctors and hospitals condemn plans by UnitedHealthcare ̵

1; the country’s largest health insurance company – to retroactively deny members’ emergency medical coverage if the UHC decides that the cause of emergency medical care was not in fact an emergency.

In the future, if one of UHC’s 70 million members submits a request for an emergency department visit, UHC will carefully review the health issues that led to the visit, the “intensity of diagnostic services performed” in the emergency department (ED) and some contexts for the visit, as well as the member’s underlying health and external conditions. If the UHC decides that the medical condition did not constitute an emergency, it will provide “no coverage or limited coverage” depending on the member’s specific insurance plan.

Emergency physicians and hospitals were quick to reprimand the plan. They say it sets a dangerous precedent for requiring patients to assess their own medical problems before seeking emergency treatment, which could end up delaying or preventing critical and even life-saving treatment.

The policy was originally set to take effect on July 1st. But in an email to Ars Thursday, UHC now says it is delaying the rollout in the midst of criticism – at least until the end of the pandemic.

“Based on feedback from our supplier partners and discussions with the medical community, we have decided to postpone the implementation of our emergency department until at least the end of the national public health emergency period,” a UHC representative told Ars in an email. . “We will use this time to continue educating consumers, customers and providers about the new policy and help ensure that people visit an appropriate service point for non-urgent needs.”

Impossible forecast

The delay is unlikely to ease critics’ concerns. After the policy was first announced last week, doctors were quick to note that it was almost impossible to assess the need for emergency care before it was actually given. Many severe conditions have symptoms that overlap with non-severe conditions. For example, chest pain may simply be a symptom of acid reflux or a panic attack, but it may also be a sign of a life-threatening heart attack. A bad headache can just be a bad headache, or it can signal a dangerous brain hemorrhage.

In a 2018 analysis published in the JAMA Open Network, researchers found that up to 90 percent of the symptoms that caused an adult to go to the emergency room overlapped with symptoms of non-emergency conditions that may be denied coverage in the future. . But the same symptoms could also be associated with life-threatening conditions.

This analysis was spurred when the second largest insurance company, Anthem, introduced a similar policy as UHC and began denying ED coverage.

In an accompanying editorial, one of the authors of the analysis – Maria Raven, head of emergency medicine at the University of California, San Francisco – noted how problematic it is to evaluate emergency medical care retroactively. “My colleagues and I investigated whether a patient’s symptoms on presentation of ED could be reliably felt as a non-emergency based on the discharge diagnosis – the diagnosis Anthem currently uses to determine medical necessity,” she wrote. “We found it impossible.”

Raven continued:

As emergency clinicians, we wait until after a reprocessing to assign a discharge diagnosis: this reprocessing is based on a detailed history and often involves blood work, imaging, and several hours of observation. That the same presentation symptoms that resulted in some patients going to the intensive care unit and others being denied coverage because the visit was considered unnecessary make it clear that patients are not assessing medical necessity.

“Condemn strongly”

In response to UHC’s planned policy, Richard Pollack, president of the American Hospital Association, reiterated Raven’s view. In a public letter addressed to UHC’s CEO and dated June 8, Pollack wrote that “patients are not medical experts and should not be expected to diagnose themselves under what they believe is a medical emergency. Threatening patients with a financial sanction for making the wrong decision can have a relaxing effect on seeking emergency treatment. ”

Overall, Pollack said the AHA is “deeply concerned” about the policy and urged the UHC to “turn around” [it] immediately. “The American College of Emergency Physicians published a similar response, saying the organization” strongly condemns “UHC’s” dangerous decision. “Like the AHA, the ACEP also noted that the policy may violate federal security measures.

“ACEP is convinced that the new policy is in direct violation of the federal cautious medical standard, which requires insurers to provide emergency care coverage based on the presenting symptoms that brought the patient to the emergency department, not the final diagnosis,” the doctors said. group in a statement.

Before telling Ars that it had decided to delay the policy, UHC had justified its plan by saying it was an attempt to cut health care costs down.

In a statement to the media Fierce Healthcare, UHC wrote:

Unnecessary use of the emergency room costs nearly $ 32 billion a year, increasing health care costs for everyone. We take steps to make care more affordable and encourage people who do not have a health professional emergency to seek treatment in a more appropriate environment, e.g.

Cost-saving measure

But the AHA and ACEP both pushed back at this point, noting that there is not much evidence to suggest widespread abuse of emergency departments. The AHA also suggested that a better way to reduce the cost of emergency care could be to give members better access and coverage for non-urgent care. Finally, the hospital association suggested that the economic argument was not strong from UHC, which has reported banner surpluses in the midst of the pandemic.

“Despite the implementation of policies to limit enrollment coverage over the past many years, UHC premiums continue to rise in most markets, as does UHC’s profits,” the AHA wrote. “As you know, UHC’s parent company UnitedHealth Group sent a 35 percent increase in operating profit over the year in the first quarter of 2021. Despite earning $ 6.7 billion in a single quarter, UHC entrants are being asked to pay more for their coverage. ”

UnitedHealthGroup also earned $ 6.6 billion in the second quarter of 2020, which was double what it earned in the same period last year.

ACEP President Mark Rosenberg was cynical in his response to the UHC’s planned policy, saying in a statement: “While we are appalled by United’s decision, we are unfortunately not surprised to see an insurance company again try to reduce its costs at the expense of necessary patient care. . ”

“You do not pay”

So far, UHC members will be spared from reviews of ED claims during the rollout delay. But even if the giant insurance company never ends up introducing the policy, the damage may have already happened. In 2018, after Anthem announced its similar policy to its members and began denying claims, it received similar setbacks and challenges. Anthem ended up effectively rolling politics back the same year and reversing decisions when members challenged demands for denial.

Yet experts were concerned at the time that only the promulgation of the policy – not its enforcement – would deter some members from seeking care. Jonathan Kolstad, an associate professor at Haas School of Business at the University of California, Berkeley, told The New York Times in 2018: “You might get just as much or more for your money by just telling people you do not want to pay. Even if you pay at the end of the day. ”

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