A recent policy change planned by UnitedHealthcare (UHC) to allow retroactive coverage denials of emergency department (ED) care has drawn a swift and pointed response from the Texas Medical Association and other state and national medical societies and specialty organizations in a pair of recent letters to UHC officials.
UHC originally planned to implement the policy starting July 1, but later tweeted it was delaying it “until at least the end of the national public health emergency period” based on “feedback from our provider partners and discussions with medical societies.”
But for TMA, there’s no appropriate time to disregard the prudent-layperson standard for emergency care. On Tuesday, TMA, the Texas Hospital Association, and the Texas College of Emergency Physicians urged the insurer to “entirely abandon” the policy in a letter to UHC. The letter supported the American Hospital Association’s (AHA’s) earlier contention that the policy change jeopardizes the health of patients.
“A delay during a public health emergency (PHE) period is appreciated,” the letter said. “However the occurrence of a PHE does not change the fact that, as AHA adroitly states it, ‘Patients are not medical experts and should not be expected to self-diagnose during what they believe is a medical emergency.’ There are several symptomatic indicators of an emergency, like shortness of breath, that patients would reasonably address using emergency services but that may not result in hospital admission upon diagnosis of the condition – for example, a panic disorder.”
UHC’s policy-change announcement claimed the insurer would evaluate ED claims “on many factors,” including the patient’s presenting problem, the “intensity of diagnostic services performed,” and other external causes and complicating factors. Claims UHC determines to be nonemergent “will be subject to no coverage or limited coverage in accordance with the member’s certificate of coverage.”
TMA policy, the letter noted, states that “patients who seek emergency care should be protected under the ‘prudent layperson’ standard as established in state and federal law, without regard to prior authorization or retrospective denial for services after emergency care is rendered. Patients must not be financially penalized for receiving emergency care from an out-of-network physician or provider.” And TMA opposes “any health plan or other payer policy that dissuades patients from seeking needed emergency care in situations where they believe their health is at risk,” the letter added.
Before the letter with Texas hospitals and emergency physicians, TMA signed on to a separate letter June 16 with the American College of Emergency Physicians (ACEP), the American Medical Association, the Federation of American Hospitals, and many others urging UHC to permanently rescind the policy. That letter noted the need for access to mental health care and substance use services “was reaching crisis levels” even before the COVID-19 pandemic.
“EDs around the country often serve as the only safety net for a fragmented mental health infrastructure,” it said. “For those in crisis for whom the ED is a lifeline for care, an added threat of a retroactive denial of coverage under this policy can be devastating.”
The original UHC policy announcement claimed a person whose initial ED claim is denied can pursue an attestation process if their emergency trip “met the definition of an emergency consistent with the prudent layperson standard.” But the June 16 letter from ACEP, TMA, and others said the damage is already done before a patient goes through that process.
“A policy of ‘deny first,’ ‘attest later’ is in itself a clear violation of the [prudent layperson] standard and will undoubtedly harm patients,” the letter said. “It will have a chilling effect on patients’ decisions to seek care, whether for themselves or for a loved one. It will take hearing only a few stories of neighbors, friends, or co-workers who were unexpectedly left with paying an entire ED bill after coverage was denied by UHC to make policyholders think twice about seeking care in an emergency. Such hesitation could be life-threatening or result in even greater costs to the health care system down the road.”