- Despite some end-of-year confusion between a powerful hospital lobby and a payer giant, UnitedHealthcare — the nation's largest private health insurer — has no immediate plans to institute stricter coverage criteria for emergency services.
- UnitedHealthcare had revised some language around its emergency and urgent care center coverage determination guideline that led the American Hospital Association to believe the payer, which covers more than 50 million people in the U.S., was instituting a harsher ER coverage policy it floated earlier last year. AHA sent a letter to UnitedHealthcare urging it to rescind the policy, saying it would result in fewer patients seeking emergency care.
- However, UnitedHealthcare clarified with the AHA in a Thursday letter that the confusion was due to unclear language in its guidelines, and that it has no intention of implementing any such new policy for its fully insured business. The Minnesota-based health insurer has revised the coverage determination to remove the language added last month.
Following concerns from the AHA regarding an apparent change to its ER coverage policy, UnitedHealthcare has clarified no changes were made — or will be made — to how it approves or denies its members' emergency claims.
The confusion stemmed from the payer updating its coverage determination guideline to comply with federal guidance released in September and clarifying some terms in its benefit coverage documents. But "our intention to align coverage definitions with the new federal guidance created confusion rather than clarifying matters," UnitedHealthcare CEO Brian Thompson wrote to the AHA.
The hospital lobby said in a statement it was pleased with UnitedHealthcare's response, received just one day after AHA sent a letter to the payer arguing against the policy.
Previously, the coverage determination appeared to suggest UnitedHealthcare would begin on Jan. 1 to review claims for emergency services to evaluate whether the patients' medical needs required ER care, one of the highest-cost sites for services in the healthcare delivery ecosystem. If the payer determined ER-level care wasn't warranted, it might retroactively elect to deny the claim.
UnitedHealthcare first attempted to implement the controversial policy last summer, but delayed it in June following fierce backlash from provider groups and patient advocates.
The new coverage criteria, which would have applied to commercially insured members, could have led to as many as one in every 10 claims being rejected, per an estimate from UnitedHealthcare's parent company UnitedHealth.
At the time, hospital interests were especially furious at the proposal, saying it would require patients with likely little-to-no medical experience to determine the severity of their injuries and illnesses, put patients on the hook for potentially exorbitant ER bills and eventually threaten provider finances due to the loss of reimbursement.
The payer originally cast the delay as only a temporary pause, at least until the end of the national public health emergency for COVID-19.
However, UnitedHealthcare confirmed with Healthcare Dive on Monday that it has no intent of moving forward with the stricter coverage criteria.
Even minute changes to coverage policies can be concerning for providers, especially during the pandemic. Despite tens of billions of dollars in federal relief funds (and little evidence the nation's largest operators are experiencing deep-seated financial troubles) hospitals continue to raise concerns about COVID-19-related financial stress.
Another factor is perennial disputes over billing between insurers and hospitals, which can often leave patients caught in the middle, bearing the brunt of unresolved claims. Providers have complained about insurers implementing more onerous policies, including requiring prior authorization for some services or publishing confusing layers of documentation requirements. Those administrative hurdles can be a major contributor to burnout, even as the healthcare workforce continues to shed jobs.
Some hospitals began flagging late last year a spike in retroactive claims denials by some major payers, including UnitedHealthcare, for care received in emergency departments. Though research suggests only about 6% of ER visits annually are actually nonemergent, misuse of emergency rooms for minor ailments costs the U.S. healthcare system $32 billion annually, according to a previous report from UnitedHealth.
Hospitals accuse payers of gatekeeping necessary care and threatening patient access, but insurers say the stricter policies are needed to control excessive prices charged by hospitals.
UnitedHealthcare isn't the first payer to attempt paring down ER expenditures: Indianapolis-based Anthem adopted a similar policy in 2018, but ultimately scaled the changes back after objections to the move poured in from legislators and doctors.