UHC Will Not Implement Emergency Care Coverage Changes

January 04, 2022 - UnitedHealthcare has clarified that it does not intend to change its emergency care coverage policies, American Hospital Association (AHA) disclosed in a special bulletin.

“AHA is pleased with UHC’s response and will continue to attempt to work with the insurer to ensure that coverage criteria are appropriate and well-defined,” AHA’s bulletin stated.

AHA shared that UnitedHealthcare and the hospital organization had communicated back and forth on the issue since AHA first published its concerns on December 29, 2021.

On December 29, AHA contacted UnitedHealthcare about the insurer’s emergency care services coverage criteria.

“We are very concerned about the impact it will have on patients and their providers,”  Rick Pollack, president and chief executive officer of AHA, wrote in his letter to UnitedHealthcare, quoted in the special bulletin.

“This new policy will make patients much more reluctant to seek needed emergency care out of fear of a coverage denial. The policy also will place an incredible burden on hospitals’ clinical workforce at a time when the demands on them are already simply extraordinary. It will pull clinicians away from the bedside to collect, review and submit paperwork, often multiple times over, to try and obtain coverage for their patients.”

However, AHA shared an update from UnitedHealthcare executives based on their latest exchange from December 30, 2021. Brian Thompson, chief executive officer of UnitedHealthcare, told AHA that there had been a misunderstanding.

Not only did UnitedHealthcare not intend to implement new coverage determination guidelines starting on January 1, 2022, but Thompson's letter also explained that the insurer did not plan to make any such changes to coverage policy for its fully-insured business.

The revisions in a December UnitedHealthcare bulletin related to coverage decision guidelines were intended to modify certain language in order to make it conform more closely to federal regulations. However, these revisions did not constitute substantive policy changes, Thompson pointed out.

“From your letter, it is clear that our attempt to clarify resulted in confusion, and we are using your feedback to be clearer regarding our intent,” Thompson wrote in a letter. “To this end, we are updating the CDG to remove the language added in the December Bulletin as well as language that was added earlier in 2021 regarding coverage criteria for emergency services.”

To ease providers’ concerns and rectify any confusion, UnitedHealthcare published a clarification in its UnitedHealthcare Commercial Medical Policy Update Bulletin for January 2022. Thompson also offered to schedule a time to discuss the matter with AHA if needed.

This conflict is an extension of the controversy that occurred only a few months earlier in June 2021 when UnitedHealthcare first announced that it planned to change its coverage criteria for emergency care services.

In June 2021, UnitedHealthcare announced that it would be changing its method for evaluating whether an emergency department met coverage standards. The new method would leverage a claims analyzer to assess a claim as emergent or non-emergent. This policy change would have applied to commercial, fully insured emergency department claims.

However, providers and provider organizations pushed back against this policy. Dissenters argued that the policy would restrict coverage for and access to emergency care services. The repercussions could be particularly detrimental during a pandemic.

In response to providers’ feedback, UnitedHealthcare delayed its policy until January 1, 2022. 

In the latest exchange with AHA, UnitedHealthcare shared that it does not intend to implement the policy.

Other payers have also come under fire for policies that may restrict access to and coverage for emergency care services. Aetna received a $500,000 fine for its emergency care policies which resulted in the payer denying 93 percent of California emergency room claims.