UnitedHealthcare wants to stop paying for non-emergency care that's provided in emergency rooms, a move that doctors and hospitals are criticizing for its potential to stop patients from quickly getting care in situations they believe are emergencies.
Officials at Minnetonka-based UnitedHealthcare, which is the nation's largest health insurer, say the goal is to encourage patients to use urgent care, clinics or even virtual visits, when appropriate, for low-level health care needs that don't require the expertise of an ER.
Starting in July, the company in most states will review ER claims to evaluate whether the visit should be paid for considering the patient's presenting problem, the intensity of diagnostic services provided and factors such as complicating health conditions. Claims deemed to not meet the criteria of an emergency medical condition, or "non-emergent," either won't be covered or will be subject to limited coverage.
"Unnecessary use of the emergency room costs nearly $32 billion annually, driving up health care costs for everyone," said Tracey Lempner, a UnitedHealthcare spokeswoman, in a statement. "We are taking steps to make care more affordable, encouraging people who do not have a health care emergency to seek treatment in a more appropriate setting."
But doctors and hospitals say the policy is driven by the company's concerns about its bottom line and could create risks for patients.
"We object to UnitedHealthcare's pending policy that asks patients to second guess their instincts that emergency care is needed," said Dr. Susan Bailey, president of the American Medical Association, in a statement. "Requiring ill and vulnerable patients to diagnose their acute symptoms at a critical and emotional moment, when time could be of the essence, is potentially harmful or even dangerous and may violate federal patient protections for access to emergency treatment."
There's only "limited evidence" that inappropriate use of ERs is a widespread problem, said Richard Pollack, president and chief executive of the American Hospital Association, in a letter to UnitedHealthcare officials. When evaluating why patients seek care in the ER, Pollack added, the insurer should consider if patients had only limited access to alternatives due to burdensome health plan rules, or because they needed care during evening or weekend hours.
"Patients are not medical experts and should not be expected to self-diagnose during what they believe is a medical emergency," Pollack wrote. "Threatening patients with a financial penalty for making the wrong decision could have a chilling effect on seeking emergency care."
UnitedHealthcare is the health insurance business operated by UnitedHealth Group, the Minnetonka-based health care giant that is Minnesota's largest company by revenue.
With the policy, the insurer still is covering emergency room care, and paying for it according to a member's health plan benefits, while encouraging alternative sites of care for non-emergencies.
Pink eye is one example of a basic health care need that might be deemed as non-emergent, said Lempner, the company spokeswoman. When such services are provided in emergency rooms, the cost can be nine times higher than at an urgent care facility, she said, and 35 times more expensive than a virtual visit.
If UnitedHealthcare determines care provided in the ER was non-emergent, doctors can submit documentation that certifies the emergency nature of the visit, Lempner said. It depends on health plan particulars whether the insurer will provide no coverage, or limited coverage, for non-emergent care.
"We've always tried to educate our members on the most appropriate place depending on the situation to go for care," Lempner said in an interview. "We want to make sure members are getting the care they need in the right location, whether that's the emergency room, or urgent care or a telehealth visit depending on the situation."
UnitedHealthcare says the policy complies with federal law including the Prudent Layperson Standard, but emergency physicians believe it is in "direct violation" of the standard.
"Over the past year, we've seen the devastating impact of when patients avoid treatment — including worsening health conditions and even death," said Dr. Mark Rosenberg, president of the American College of Emergency Physicians, in a statement. "This new policy will leave millions fearful of seeking medical care, just as we're getting hold of the COVID-19 pandemic and trying to get as many people vaccinated as possible."
The American College of Emergency Physicians filed a lawsuit in 2018 after Indiana-based Anthem, another national health insurer, introduced a policy in some states to retroactively deny coverage for some ER services. In a 2020 statement on the ongoing litigation, Rosenberg said his group was fighting to "ensure the millions of patients our members treat each year are not deterred from seeking emergency care when they need it."
In a 2019 report, UnitedHealth Group estimated there were 18 million avoidable emergency department visits per year, at a cost of $32 billion in the U.S. It found the average cost of treating 10 common conditions that could be handled in primary care clinics would cost $2,032 in an emergency department — about $1,800 more than in primary care.
Emergency department costs were higher, the report said, due to hospital facility fees as well as higher prices for lab, pathology and radiology services.
The new policy applies to employer group health plans that are "fully insured," meaning the employer pays UnitedHealthcare to take the financial risk for claims. About 7.8 million people were covered through these UnitedHealthcare plans at the end of March.