- The American Hospital Association sent a letter to the CEO of the nation's largest commercial insurer, UnitedHealthcare, asking the payer to abandon a new ER policy that could potentially deny coverage if a visit is later deemed a non-emergency.
- AHA called the policy "dangerous" and said it will lead to a "chilling effect," as patients may avoid the ER over fears a visit may not be covered.
- The group did not explicitly say UnitedHealthcare is not following the law, but implied as much. "This is exactly why federal law requires insurers to adhere to the prudent layperson standard, which prohibits insurers from putting up coverage roadblocks to emergency services," AHA said in the Tuesday letter to UnitedHealthcare CEO Brian Thompsom.
UnitedHealthcare recently notified providers that they will be taking a closer look at ER claims beginning July 1 in an attempt to root out unnecessary visits.
If an ER trip is later deemed to be a non-emergency, like a visit for pink eye, it is "subject to no coverage or limited coverage," the provider alert stated.
The move has generated fierce pushback from the provider community. The policy comes at a time when ER visits are already sagging due to the COVID-19 pandemic, even as other visits return to normal. Some fear that patients who refuse to go to the emergency room may have worse outcomes.
"Threatening patients with a financial penalty for making the wrong decision could have a chilling effect on seeking emergency care," AHA said in its letter.
The American College of Emergency Physicians also spoke out against the policy.
"ACEP firmly believes that the new policy is in direct violation of the federal Prudent Layperson Standard, which requires insurance companies to provide coverage of emergency care based on the presenting symptoms that brought the patient to the emergency department, not the final diagnosis," according to a statement issued Tuesday.
UnitedHealthcare has said there is a process in place for facilities to contest a visit that was deemed a non-emergency.
But AHA said it wants some assurances that that process will result in a visit being covered.
"Can UHC confirm in writing that if the facility attests that a case met the prudent layperson standard that the services will be covered?" the group asked.
UnitedHealthcare isn't the first to try to implement this kind of policy. Anthem, one of the nation's largest insurers, set in motion a similar policy regarding ER visits a few years ago and was met with swift pushback.
Ultimately, Anthem scaled back some of the policies after the move attracted attention of legislators.