Those with employer paid UnitedHealthcare insurance plans may unexpectedly have to pay out of pocket for their next visit to the Emergency Room. In a controversial move, on June 9, 2021, UnitedHealthcare told its network hospitals in 34 states, including Florida, that it may deny claims for visits to the emergency room if the insurance company determines, based on its own analysis, that the condition leading to the visit to the emergency room is “non-emergent.”
In the notice to hospitals, UnitedHealthcare states that emergency room claims will be evaluated based on the patient's presenting problem, the intensity of diagnostic services performed, and other complicating factors or causes.
This new policy has faced heavy opposition from national groups such as the American Hospital Association, whose President and CEO Ricard Pollack called on UnitedHealthcare to immediately reverse this policy. In his letter, Pollack stated that “patients are not medical experts and should not be expected to self-diagnose during what they believe is a medical emergency,” and “threatening patients with a financial penalty for making the wrong decision could have a chilling effect on seeking emergency care…this is dangerous for patients' health at any time, but is particularly unsafe in the midst of a public health emergency," he said, referring to the COVID-19 pandemic.
Partner, Sheba Abraham, finds this new policy very concerning. “To avoid crippling debt, people are going to make risky health care decisions, not only for themselves, but for their young children and vulnerable loved ones. If you go to the hospital believing you are experiencing a medical emergency, and your concern turns out to be a false alarm, instead of breathing a sigh of relief, you may be slapped with a $5,000-$15,000 bill for a visit to the hospital,” says Ms. Abraham. This policy will leave people with no medical training, hesitant to seek medical care out of fear that their diagnosis will not qualify as an “emergency.” This policy will also lead many to disregard after-hours nurses or on-call primary care doctors when they instruct a patient on the phone to go to the hospital “to get checked out to be safe.” It is unsound to be denied health insurance benefits based on 20/20 hindsight reached with the benefit of expensive diagnostic equipment and trained physicians board-certified in emergency medicine. While UnitedHealthcare indicates that providers will have the opportunity to contest the insurer's decision by submitting an “attestation” after the insurer makes its determination, this process could take many months and will inevitably place an unreasonable burden on medical providers who are already overwhelmed.
UnitedHealthcare claims that this new policy is designed to reduce health care costs for their members through bringing down the costs of unnecessary emergency room use. However, it appears that this is just another profit maximizing strategy of the insurance giant. In fact, UnitedHealthcare has just announced that first quarter 2021 revenues of $55.1 billion grew by $4 billion or 7.9% compared to last year. Its first quarter operating earnings of $4.1 billion also jumped from $2.9 billion last year. With such favorable financial forecasts, it is hard to fathom how such onerous policies can be justified.
Sheba Abraham also notes how this policy will affect victims of car accidents with traumatic brain injury or other types of injuries that are not visibly apparent. “Immediate access to emergency room physicians with state of the art diagnostic tools is critical to early diagnosis and treatment. Sometimes, my clients are lucky and turn out to have only minor injuries. But other times, it's that cautious visit to the emergency room that reveals an intracranial hematoma that requires immediate medical intervention.”
After mounting backlash and criticism from hospitals and doctors' groups, UnitedHealthcare announced that they will delay implementation of this new policy until after the pandemic. "Based on feedback from our provider partners and discussions with medical societies, we have decided to delay the implementation of our emergency department policy until at least the end of the national public health emergency period," Tracey Lempner, spokeswoman for the Minnesota-based insurer, said in a statement. Officials from the American Hospital Associated are urging the major insurance company to not simply delay, but to abandon the policy altogether. Sheba Abraham joins patient advocacy groups and urges UnitedHealthcare to consider the serious risks to patients and abandon this policy implementation altogether.
Count on the law firm of Goldberg Noone Abraham to keep you aware of any major changes as they are enacted.