They've Been Doing It Forever
UnitedHealthcare recently sparked outcry by saying it may retroactively deny ER claims — but documents suggest it’s been doing so for years.
by ANDREW PEREZ
The man’s son had been vomiting, feeling nauseous, and experiencing bad heartburn for several weeks. The child’s pediatrician eventually made the call: It was time to take the boy to the ER.
The father, who requested anonymity, wasn’t the sort of person who went to the emergency room on a whim. He was an internal medicine physician after all, so he tried to avoid ER visits as much as possible. But in late 2019, he listened to the boy’s doctor and took his son to the ER near where they lived in Florida, then took him a second time when he once again couldn’t hold down food.
The decision ultimately seemed to make sense. Tests found the boy was suffering from a newly onset auto-immune disorder. But the family’s insurer, UnitedHealthcare, refused to pay the bills, which totaled $7,000 — $4,000 of which the hospital’s physician services company has since demanded from the family.
The insurer denied one claim, asserting it needed additional information, and refused to consider two other charges, saying the “documentation doesn't support the level of service billed.” The family has tried appealing, but, according to the father, the insurer has said the physician documentation did not support the ER trip being an emergency.
To the father, who has been a doctor for more than a decade, that response made no sense. “We were advised to go there, so there's no way that it's not [an emergency],” he told The Daily Poster. “It required an ER visit and an inpatient stay to get a diagnosis.”
The Florida-based physician isn’t the only one concerned about the ER policy of UnitedHealthcare, the nation’s largest insurer which last year logged a quarter trillion dollars of revenue while its CEO made $42 million. Health care advocates recently expressed alarm after the company announced it was planning to more closely scrutinize emergency room visits, and potentially deem them “no coverage or limited coverage” events.
The American College of Emergency Physicians (ACEP) warned that “UnitedHealthcare is expecting patients to self-diagnose a potential medical emergency before seeing a physician, and then punishing them financially if they are incorrect.”
In response to the outcry, UnitedHealthcare hastily announced it would postpone the policy at least until the end of the COVID-19 pandemic. However, consumer complaints reviewed by The Daily Poster — including the incident detailed above — indicate the insurance giant has already been denying emergency room claims, asserting that patients’ medical scares weren’t real emergencies, leaving them on the hook for massive bills.
A UnitedHealthcare spokesperson requested that we hold this story a day for them to review the specific patient complaints, but ultimately did not respond to our questions about their denials.
She noted that, “Based on feedback from our provider partners, we have decided to delay the implementation of our emergency department program 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 program and help ensure that people visit an appropriate site of service for non-emergency care needs.”
As the Biden administration doubles down on subsidizing the private insurance industry rather than embracing Medicare for All, UnitedHealthcare’s claim denials are part of a broader practice across the insurance industry.
For-profit health insurance companies regularly refuse to pay for medical services because denials boost their profits, and they have little incentive not to deny coverage. In 2019, health insurers rejected roughly 17 percent of claims for in-network services involving patients on individual Affordable Care Act health insurance plans, according to data from the Kaiser Family Foundation. Only a tiny fraction of patients appeal the denials.
In 2018, Anthem Blue Cross Blue Shield enacted a similar emergency room policy to the one announced by UnitedHealthcare. ACEP sued Anthem over the policy, and the company has quietly limited its use. Last year, California health care regulators fined health insurer Aetna for wrongfully denying members' emergency room claims 93 percent of the time, in violation of state laws protecting ER patients.
The issue of rampant claim denials extends to Medicare Advantage plans, coverage offered to Medicare beneficiaries by private insurers. A few years ago, the federal Health and Human Services Department (HHS) reported that “there are persistent problems related to denials of care and payment in Medicare Advantage.” HHS reviewed Medicare Advantage contracts covering 15 million beneficiaries in 2016 and found nearly 37 million claim denials — or 2.4 claim denials per customer.
“It’s Bull”
The ongoing pandemic has proven to be a jackpot for health insurance companies, as patients have avoided doctors and trips to the emergency room as much as possible.
UnitedHealthcare took in $257 billion in revenue last year. It also reported more than $15 billion in profit — an 11 percent increase from the previous year. Despite its COVID profit boom, the company chose to announce a policy likely to deter people from visiting emergency rooms.
On June 8, UnitedHealthcare wrote: “Effective July 1, 2021, we will enhance our capabilities to assess emergency department (ED) facility commercial claims to determine if the ED event was emergent or non-emergent, according to existing plan provisions, in most states.”
The company said that emergency room claims would be evaluated based on a number of factors including “the patient’s presenting problem” and “the intensity of diagnostic services performed.”
“Claims determined to be non-emergent will be subject to no coverage or limited coverage in accordance with the member’s certificate of coverage,” the company wrote, adding that patients would be given an “opportunity to complete an attestation if the event met the definition of an emergency consistent with the Prudent Layperson Standard.”
The Federal Prudent Layperson standard, enacted by Congress in 1997, defines an emergency medical condition as “a medical condition manifesting itself by acute symptoms of sufficient severity (including severe pain) such that a prudent layperson, who possesses an average knowledge of health and medicine, could reasonably expect the absence of immediate medical attention” to result in serious harm.
The point of the Prudent Layperson Standard is to protect patients and allow them to seek emergency care if they believe it’s necessary. ACEP said the UnitedHealthcare policy would violate the prudent layperson standard and “leave millions fearful of seeking medical care.”
The insurer quickly announced it “decided to delay the implementation of our emergency department policy until at least the end of the national public health emergency period.”
But Karen Schapira, a Florida lawyer who often represents health care providers, told The Daily Poster that UnitedHealthcare already has a history of retroactively denying ER claims.
“They're claiming to have put [the policy] off for now, in response to the COVID pandemic, and they'll only begin sometime in the future,” she said. “It's bull, because they've been doing it forever.”