UnitedHealthcare will begin denying some emergency department claims for its commercial members if an internal evaluation finds the services were nonemergent.
The policy, which takes effect July 1 in most states, is similar to Anthem's policy, under which the insurer reviews diagnoses after members' emergency room visits. If the condition is determined to be nonemergent, UnitedHealthcare may not fully cover the ER visit.
UnitedHealthcare will evaluate ER claims based on a patient's presenting problems, the intensity of diagnostic services performed, and other patient factors and external causes, according to the insurer.
If claims are denied, providers will be able to complete an attestation "if the event met the definition of an emergency consistent with the prudent layperson standard," according to UnitedHealthcare. The insurer will send a notice about an attestation electronically to the care facility.
"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.
Retroactive denial policies for ER care have drawn criticism from provider groups, who argue the policies violate federal law. A 2018 study of Anthem's policy found it could land 1 in 6 patients with denied claims if widely adopted, according to JAMA Network.
An investigation from The New York Times found that Anthem denied more than 12,000 emergency care claims from patients in Missouri, Georgia and Kentucky in the second half of 2017 on the grounds they were "avoidable," but ended up paying most of the claims anyway when they were challenged.