In a surprising new policy from UnitedHealthcare (UHC), the insurer lays out vague criteria that will allow the company to deny coverage for care delivered in an emergency room. The surprise is that it comes just six months after the insurer attempted a similar policy but withdrew it after significant backlash. At the time, UHC publicly stated that it would not implement a new emergency service coverage policy at least until the end of the public health emergency. It also comes just two months after news that UnitedHealth Group’s latest profit rose past the $4 billion mark for the third quarter of 2021, according to Fierce HealthCare
“The public health emergency is not over. COVID case counts continue to increase across the country, including right here in Wisconsin. Hospitals are struggling to meet the needs of a growing number of patients, while continuing to address capacity challenges and a fatigued health care workforce,” said WHA Senior Vice President of Public Policy Joanne Alig. “While these kinds of insurer obstructions certainly shouldn’t be implemented at this critical time, they really shouldn’t be implemented ever,” Alig continued.
At issue is whether an insurer should be able to determine after the fact that a patient should have sought care in an emergency room or somewhere else. Federal law and state law in Wisconsin require that insurers cover emergency services; and in doing so, they are required to apply what is known as a “prudent layperson standard,” which is an important patient protection. The prudent layperson standard essentially says that if a reasonable person with an average knowledge of health and medicine thinks his or her health is in jeopardy based on his or her symptoms, then it is an emergency medical condition.
According to the American Hospital Association (AHA), the new criteria at first glance appear to be an improvement over the previous version, but come with a significant caveat that, in the end, would undercut any seeming improvements. Under UHC’s new policy, the insurance company will continue to take into account the final diagnosis and “other pertinent information” in determining after the fact if the visit was an emergency. Providers are particularly concerned with the term “other pertinent information,” which gives the company significant latitude to deny coverage after the fact. Like the previous version, the uncertainty will make patients reluctant to seek emergency care.
AHA also points out that the new policy will place an incredible administrative burden on the health care workforce. “The risk of excessive administrative burden is particularly high, as this policy allows UHC to manipulate its coverage criteria through the vague criterion of ‘other pertinent information’,” the association states. “Failure to clearly establish coverage criteria leaves both patients and providers in the dark, and such ambiguous terms will almost certainly result in providers being asked to send to UHC voluminous amounts of paperwork to satisfy whatever information it requests to in order to approve coverage.”
While the policy is expected to go into effect Jan. 1 in all states, AHA in a letter urged UHC to reconsider its misguided coverage criteria.