Hospitals and physicians are condemning a new UnitedHealthcare policy under which the insurer may retroactively deny some emergency department claims.
Effective July 1 across most states, UnitedHealthcare may not fully cover an ER visit for its commercial members if it determines that their condition didn't warrant a trip to the ER. It's similar to a policy Anthem has in place for ER care.
In a June 8 letter to UnitedHealthcare's CEO Brian Thompson, American Hospital Association CEO Rick Pollack said the new policy would jeopardize patient care and should be immediately reversed.
"Patients are not medical experts and should not be expected to self-diagnose during what they believe is a medical emergency. Threatening patients with a financial penalty for making the wrong decision could have a chilling effect on seeking emergency care," according to the letter, emailed to Becker's.
The AHA, along with the American College of Emergency Physicians, argue that the policy violates the federal prudent layperson standard. The standard requires health insurers to cover emergency health services based on presenting symptoms as opposed to final diagnosis.
UnitedHealthcare said providers can complete an attestation if the insurer denies a claim in which "the event met the definition of an emergency consistent with the prudent layperson standard."
"If the attestation is submitted within the required time frame, the claim will typically be processed according to the plan's emergency benefits," according to UnitedHealthcare.