- NYC Health + Hospitals, the nation's largest public health system, is seeking $11.5 million for inpatient medical claims denied by UnitedHealthcare.
- A spokesperson for the health system told Modern Healthcare that the majority of claims were for ER visits involving patients covered by UnitedHealthcare's Medicaid program and Medicare plan.
- NYC Health & Hospitals' contract with UnitedHealthcare requires the hospital system to seek arbitration, which will happen this summer. The health system said it is also reviewing its managed care contracts and may seek arbitration with other insurers down the road.
UnitedHealthcare is not the first major payer to take a closer look at ED visits. Last year, Anthem announced a controversial ER policy to stop paying visits it later deemed medically unnecessary. Providers have since pushed back against the program, saying it forces patients to make decisions doctors should be making and could cause people to delay or avoid needed care. Anthem has since amended its ER policy to allow for a number of exceptions.
While Anthem’s policy looks to move patients away from EDs to less expensive locations like urgent care centers and retail clinics, UnitedHealth’s policy change is about making sure hospitals are billing properly.
Emergency services are lucrative for hospitals, which face growing competition from retail clinics and urgent care centers. Prior authorizations, typically requiring an extra layer of approval before paying for a treatment, are one way that payers have looked to contain healthcare costs.
Prior authorizations are not popular, and can be a headache for hospitals, payers and patients. A December 2016 American Medical Association survey reported that physicians were completing an average of 37 prior authorizations each week, which took about 16.4 hours to process. Moreover, a more recent AMA survey found 92% of physicians report prior authorizations have a negative impact on patient clinical outcomes.