Backlash forces UnitedHealthcare to delay policy that would deny ER visit coverage

A major insurance company wants to cut back on covering visits to the emergency room, but pushback has led UnitedHealthcare to announce they will delay the new policy until after the pandemic is declared over.

If UnitedHealthcare goes through with it post-pandemic, people on a Medicare Advantage Plan or Medicaid would not be affected.

The aim is to have the insurance company and their customers save money but experts say the consequences could be more costly or even deadly.

The American College of Emergency Physicians (ACEP) strongly condemned the decision by UnitedHealthcare to retroactively deny emergency care claims.

“While we’re dismayed by United’s decision, we are not, unfortunately, surprised to see an insurance company once again try to cut its costs at the expense of necessary patient care,” said Mark Rosenberg, DO, MBA, FACEP, president of ACEP. “UnitedHealthcare is expecting patients to self-diagnose a potential medical emergency before seeing a physician, and then punishing them financially if they are incorrect.”

The health insurance giant was slated to instate a new policy on July 1, but after public backlash, has decided to defer implementation until the pandemic is over.

ACEP said they believe that the new policy is in direct violation of the federal Prudent Layperson Standard, which requires insurance companies to provide coverage of emergency care based on the presenting symptoms that brought the patient to the emergency department, not the final diagnosis.

According to the Centers for Disease Control and Prevention (CDC), only 3% of emergency visits are “non-urgent.” With 90% of symptoms overlapping between non-urgent and emergent conditions, in many instances, even physicians cannot know if a patient’s symptoms require emergency treatment without conducting a comprehensive medical examination. They say it’s the very reason the Prudent Layperson Standard exists, to protect patients.

Throughout the pandemic, ACEP and other medical societies have been encouraging the public to not delay medical care, especially in case of an emergency. ACEP says decisions like this from insurance companies could severely undermine collective efforts to get the virus under control.

Anthem, which operates Blue Cross, announced a similar policy in the past, leading to a lawsuit from ER doctors. That litigation is still continuing.

For Lori Nespoli, the new policy is not fair.

“I’m like, I should just go to the ER, I’m having an issue. But then again, it’s like, do you ride it out? Like, you just don’t know,” Nespoli said. “I’ve had a primary care [doctor] tell me to book an appointment with a specialist. If I can’t get into a specialist and I’m still having issues, just go to the ER, because it would just be faster to get tests done.”

The idea is to get people to use less expensive options for non-emergencies, like urgent care clinics.

“The cost reduction they may be expecting may not really exist, depending on who is looking for that help or not looking for help,” said Amir Neto, an economic expert with Florida Gulf Coast University.

Neto said people might start to avoid treatment which could make their health deteriorate and end up costing more.

And people with lower incomes will be the most affected.

“It’s really hard for us to tell if it’s an emergency or not,” Neto said. “That’s the big thing.”

Nespoli thinks about her sister who died of an aneurysm last year.

“It’s always in the back of my mind,” Nespoli said. “Someone like her who should have gone to the emergency room, but had she called the doctor probably on Friday on a holiday weekend, they would have told her to just get out, see an orthopedic or put ice and heat on it.”

Neto said now is time to reconsider your insurance provider, if you can, and save for potential health costs.

Lee Health feels the policy could be dangerous.

They sent WINK News the following statement: “Lee Health stands with the American Hospital Association in encouraging UnitedHealthcare to reconsider their new emergency department coverage policy. This policy asks patients to make medical decisions they are not trained to, and could lead to catastrophic health outcomes if people become hesitant to seek emergency care when they truly need it. This is a dangerous policy that is not in the best interest of patients or their safety.”

American Hospital Association President and CEO Rick Pollack had this to say: “Today’s announcement from UnitedHealthcare to delay its new policy on emergency coverage offers a temporary reprieve for patients, and we urge its full and permanent reversal. If enacted, this policy would have a chilling effect on patients seeking emergency services, with potentially dire consequences for their health. It is also part of an unfortunate pattern of commercial health insurers denying care for needed services. Patients should have the confidence to seek the emergency care they need without worrying about coverage being denied. There is no justification for these restrictions now or after the public health emergency.”

Here is UnitedHealthcare’s response:

“We have decided to delay this program. 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. 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.”