UnitedHealthcare May Deny Emergency Visit Coverage

Within days of announcing a policy shift aimed at cutting back on reimbursements for emergency room care, the major insurer retreated — for now.,

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Just days after UnitedHealthcare announced that it would stop paying for emergency room hospital visits that it deemed nonurgent, the company faced mounting opposition and said on Thursday it would delay the policy shift until the pandemic had ended.

Under the new policy, which was to go into effect next month, UnitedHealthcare, the giant insurer, had planned to scrutinize the medical records of its customers’ visits to emergency departments to determine if it should cover those hospital bills. But in the last week, several major hospital and doctor groups demanded that United abandon the policy.

“Plain and simple, this is a very misguided policy that could have a chilling effect for people going to the emergency room,” Rick Pollack, the chief executive of the American Hospital Association, a trade group, said earlier this week.

In a letter to UnitedHealthcare’s chief executive, Mr. Pollack sought a policy reversal and emphasized that the pandemic had demonstrated the risks of discouraging patients from seeking care.

“This is dangerous for patients’ health at any time, but is particularly unsafe in the midst of a public health emergency,” he said.

On Thursday, United acknowledged the concerns raised by many groups, in announcing its decision to delay the new policy: “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,” it said in a statement.

Top U.S. health officials have not said what would lead them to declare an end to the crisis.

Hospitals and doctors had raised concerns that the new policy signaled a return to a contentious tactic used by health insurers to clamp down on care they argued should be delivered in a less costly setting.

Anthem, another large insurer that operates for-profit Blue Cross plans, announced a similar policy several years ago that led to a political backlash and a federal lawsuit from emergency room physicians claiming it violated federal protections for patients seeking emergency care. Anthem said it could not comment because of the continuing litigation.

The policy shifts seemed puzzling when there had already been significant declines in emergency room visits throughout the pandemic into this year, which resulted in considerable savings and lower costs for insurers. Emergency room visits across the country fell by 27 percent in 2020, compared with the previous year, according to Gist Healthcare, a consultant, which predicts that people with less serious conditions will continue to stay away.

United’s decision seemed aimed at making sure people did not go back to their old habits, even as hospitals might try to persuade more people to return, said Chas Roades, a co-founder of Gist. He did not believe United was likely to generate significant savings from the program and could experience a backlash. “I can’t quite believe the juice is really worth the squeeze on this policy right now,” he said.

But many people also ignored worrisome symptoms and avoided seeking care, even if they were experiencing heart problems or other ailments. Although the coronavirus crisis has eased in the United States, people are still hesitant to seek medical help in crowded settings, and the numbers of patients being seen in emergency rooms have not rebounded.

Physician groups were also critical of the decision to deny coverage for emergency visits that United considered nonurgent. “We object to UnitedHealthcare’s pending policy that asks patients to second guess their instincts that emergency care is needed,” Dr. Susan R. Bailey, the president of the American Medical Association, said in a statement. “Patients should not be expected to self-diagnose to determine whether, for example, chest pain is a heart attack or indigestion.”

Others noted that such a policy could thwart efforts by federal officials to enlist emergency rooms as another option for reaching more people for immunization against the coronavirus.

“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,” Dr. Mark Rosenberg, the president of the American College of Emergency Physicians, said in a statement earlier this week.

If United still goes ahead change later on, the policy would apply to millions of people in United’s fully insured plans in 35 states, including New York, Ohio, Texas and Washington. People covered through an employer that is self-insured or enrolled in a Medicare Advantage plan or Medicaid would not be affected. The policy would have exempted care for children under 2 years old.

United had insisted that its policy is not aimed at preventing customers from going to the emergency room to rule out a heart attack if they have chest pain or to address a medical crisis. The insurer said it would take into account the original reason for the visit, any laboratory work or imaging performed and whether there were existing medical conditions or other factors that could have warranted a visit. A hospital could still attest to the emergency needs, and patients can ultimately appeal.

“Unnecessary use of the emergency room costs nearly $32 billion annually, driving up health care costs for everyone,” the company said in a statement on Monday. “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, such as an urgent care center. If one of our members does receive care in an emergency room for a nonemergent issue, like pink eye, we will reimburse the emergency facility according to the member’s benefit plan.”

During the pandemic and for months of lockdown, non-Covid care, ranging from knee surgeries to mammograms to emergency room visits, fell. Insurers, including UnitedHealth Group, the company’s parent, reported robust profits throughout the crisis. While some experts worried that the delays in care would cause patients’ conditions to worsen, others argued the decline might provide evidence of unnecessary care like screenings.

United’s initial decision was viewed by some critics as a message directed at hospitals.

“They see this as a way to get the upper hand in their perpetual battle with providers,” said Jonathan Kolstad, a health economist at the University of California, Berkeley.

It was the latest example of the insurer clashing with doctors and hospitals, said Michael R. Turpin, a former United executive who is now an executive vice president at USI, an insurance brokerage that helps businesses find coverage. Most recently, United’s sparring with anesthesiologists resulted in lawsuits from a sizable physician-owned practice backed by private-equity investors, and the hospitals complain that United has adopted other policies that make it difficult for patients to get their care covered.

A few consumers are already battling insurers and some providers over billing for Covid vaccines, prompting the federal government to remind the participants that it is illegal to bill patients for those costs.

There is also increasing evidence that some of the people who didn’t go to emergency rooms during the pandemic would have been better off seeking care. A recent study in Health Affairs by researchers from the MIT Sloan School of Management, working with Boston Emergency Medical Services, found evidence of an increase in heart attacks that had occurred out of the hospital, particularly in low-income neighborhoods.

The people delaying care may be among those populations that are already the most vulnerable, according to a study by researchers from the Centers for Disease Control and Prevention, which studied the makeup of individuals who said they had put off care. “Avoidance of urgent or emergency care was more prevalent among unpaid caregivers for adults, persons with underlying medical conditions, Black adults, Hispanic adults, young adults, and persons with disabilities,” the researchers wrote.

Dr. Damian Caraballo, an emergency room doctor in Tampa, Fla., points out that patients are simply unable to tell the difference between an ovarian cyst, which is usually not life-threatening, and appendicitis, which is. The penalty for being mistaken could amount to hundreds, if not thousands, of dollars. “The last thing I want is for patients to get hosed,” he said.

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