Just three days after announcing a new policy aimed at reducing Emergency Room (ER) coverage, United Healthcare (UHC) delayed the policy’s July 1st start date. The reversal was in response to a fierce backlash from the American Hospital Association, the American College of Emergency Physicians and others. But before we get to the backlash, let’s see how the policy would have increased your ER costs.
When UHC Would Not Pay Your ER Bill
UHC would decide whether or not to pay for your ER visit by reviewing your claim after the fact. In other words, long after you’ve left the ER. The claim would be considered “avoidable” if UHC determined you could have been treated at an urgent care clinic or doctor’s office. Your claim would be denied. That means they wouldn’t pay the bill. You’d have to pay all or most of it.
Providers’ Concerns over Reduction in ER Coverage
UHC’s policy enraged providers primarily for two reasons. First, doctors make a diagnosis only after completing a full work-up and assessment. If trained professionals don’t know what’s wrong with you until their evaluation is done, how are you supposed to know? You don’t. That’s exactly why we’ve always been told to get medical help immediately if we have life-threatening symptoms, like chest pains. Let the doctor figure out if our chest pains are due to a heart attack or indigestion. Yet this bill indirectly tells us to do just the opposite. Only go to the ER if you are certain you have a life threatening condition. Otherwise you’ll pay the bill. That’s wrong. And it take us to the providers’ second concern.
Researchers have documented similarities between symptoms for life-threatening and non-life-threatening conditions. A 2018 study published in the Journal of the American Medical Association found that one insurer’s list of non-emergency diagnoses (those that lead to “avoidable” ER visits) shared the same symptoms as nearly 90% of all ER visits.
The most common symptoms for potentially denied claims were chest pain, abdominal pain, and shortness of breath. Any of those symptoms would make you think you’re having a heart attack or other life-threatening event. Without a moment’s hesitation, you’d to go to the ER. But with UHC’s policy, you instead might think, “I could be wrong. This may be nothing. I’ll get stuck with a huge ER bill. I’ll stay home and call my doctor tomorrow.” Then you end up having a massive heart attack or something equally serious that leads to a debilitating long-term illness or death. That’s exactly what doctor’s don’t want to see happen.
Why UHC Wants to Reduce ER Coverage
What did UHC want to see happen? A reduction in their ER costs. According to UHC’s 2019 report, a trip to the ER for a non-emergency condition costs 12 times more than treatment in a doctor’s office. In addition, ER claims are expected to increase from $3.5 trillion in 2017 to $6 trillion by 2027.
The report goes on to say that two-thirds of ER visits by people with private insurance were avoidable. Their diagnosis was for a condition that could have been treated in a doctor’s office or urgent care center. Thus the new policy’s reliance on a diagnosis to determine whether or not UHC would pay your ER bill.
The policy was only going to apply to private insurance plans. These are the fully insured plans offered by many small and medium sized employers. The policy wouldn’t have applied to Medicare, Medicaid or self-funded plans (often offered by larger employers).
UHC’s Policy Delay
UHC acknowledged the providers’ concerns, delaying the policy’s effective date until the pandemic has ended. The key word is “delaying.” The policy is not permanently off the table. Unless they change their minds, UHC will eventually activate the policy to reduce ER coverage.
According to a UHC spokesperson, “We will use this time to continue to educate consumers, customers and providers on the new policy and help ensure that people visit an appropriate site of service for non-emergency care needs.”
While I strongly support helping people understand how to use their insurance benefits, education isn’t the answer to this problem. In fact, a 2019 US News & World Report article on avoidable ER visits included this statement from UHC:
“Uneven access to timely, consumer-friendly, and convenient primary care options is a longstanding problem, and there is a need to bolster and expand primary care capacity through urgent care centers, physician offices, and nurse practitioners.”
There is no evidence that this new policy addressed any of those issues. Instead, it would only punish consumers who did what they’ve always been told to do: get emergency care when experiencing potential life-threatening symptoms.
What’s Next
In a letter to UHC, the Federation of American Hospitals (FAH) implored the insurer to permanently rescind the policy. Let’s see if UHC heeds FAH’s warnings about the policy putting people’s “health and potentially even their lives in peril,” by never implementing the policy.
Perhaps FAH’s reminder that the policy is not in compliance with the “prudent layperson” federal law will get UHC’s attention. Especially since Anthem, which implemented a similar policy in 2017, is still in litigation over that very issue.
I’ll follow the story and keep you updated!