ER Coverage is Changing

UnitedHealthcare originally announced it would change its claims processes for visits to an emergency department in most states starting on July 1st, 2021. Due to public pushback, the insurance carrier has announced that it will be withholding this policy change until the end of the national public health emergency period enacted due to the COVID-19 pandemic.

“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,” UHC announced in a statement just days after the new policy was announced. “We will use this time to continue to educate consumers, customers and providers on the new policy and help ensure that people visit an appropriate site of service for non-emergency care needs.”

UHC will be changing its evaluation process of the cause of an emergency room visit, classifying the event as either emergent or non-emergent. If a claim is found to be a non-emergent visit, the cost of employees’ care could be subject to limited coverage or no coverage.

UHC’s evaluation of visits to emergency departments will be based on existing plan descriptions. The insurance carrier will take other factors into account, including:

  • The patient’s presenting problem
  • The intensity of diagnostic services performed
  • Other patient complicating factors and external causes

This applies to care received at in-network and out-of-network providers.

In order to avoid a larger number of high claims for non-emergent care, Katz/Pierz encourages any employers affected by this carrier update to educate their employees about the right place to seek medical care in specific situations. Below is a PDF that details how and when employees should seek care in an emergency facility. Employers can also visit uhc.com/quickcare for more information from UHC about appropriate care locations.

An emergency room is the most expensive place to receive care. Sometimes it’s necessary, and other times alternative venues can provide quality care at a much lower cost. While this announcement comes from UHC, we see that this is a trend already being adopted by other carriers. Please reach out to Katz/Pierz with additional questions on this topic and ways to remind your employees about the appropriate use of the ER.

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