Skip to Content

United announces plans to deny ED claims retroactively

You’ll want to be sitting down for this one—Modern Healthcare’s June 4 story is a doozy.

Let’s say you have a pain somewhere in your gut in the middle of the night. You’re not sure where it came from; it gets worse and then better, but it’s not going away. It could be indigestion, which can be cured by a trip to the medicine cabinet—or it could be appendicitis, which requires a trip to the emergency room.

Now, let’s say your health insurance company just announced a plan to scrutinize emergency room visit claims and will be billing patients for those it deems less (or not) urgent. How much of a gamble are you willing to take? That’s the quandary into which UnitedHealthcare recently dropped its members, as it announced a plan to review their Emergency Department (ED) visits from top to bottom, with an eye toward weeding out claims that don’t meet its criteria for what constitutes an emergency. What are those criteria? It’s unclear.

As Modern Healthcare shares, United’s policy on approving or denying patient claims entails reviewing every step of its members’ journey, from their reasons for going to the ED to any diagnostic or other services that are provided while there, as well as the outcome of the visit. Claims for visits that aren’t found to be emergencies, according to United’s review, can be denied.

For the moment, it looks like you’re safe to take the risk of visiting your local ED. After a barrage of criticism, United has agreed to “pause” implementing this policy (due, they say, to concerns around the COVID-19 pandemic). It makes us wonder why United is backing off so readily, if they genuinely believe that this is a sensible policy. Our guess is that the insurer thought it could quietly implement these new rules without catching anyone’s attention, but once the word actually hit the streets, they saw the writing on the wall and quickly distanced themselves. The only question now is: How long will United be willing to “pause” on implementing this policy?

Original Article:

Subscribe to Un-covered Essentials

Insurer policies limit coverage and disrupt patient care, while producing record profits for corporate shareholders. Stay informed with the Un-covered newsletter.