Insurance giant's new ER policy called 'dangerous' by critics.

[mdbl]

Source: USAToday

Insurance giant UnitedHealthcare is cracking down on emergency room visits with a new policy starting July 1 that the American Hospital Association says will jeopardize patients’ health and threaten them with financial penalties. The American College of Emergency Physicians said it fears the change will cause patients to avoid using emergency rooms because they will be responsible for their hospital bills when UnitedHealthcare rejects them.

UnitedHealthcare this month told its network hospitals in 34 states including Florida that it will assess emergency room claims to determine if visits were indeed medical emergencies. Claims that are determined not to be tied to emergencies will be subject to no coverage or limited coverage based on the patient’s insurance plan, according to the insurer’s notice sent to hospitals. As many as 1 in 10 claims could be rejected, said Tracey Lempner, spokeswoman for the Minnesota-based insurer.

UnitedHealthcare’s policy affects commercially insured patients with employer-sponsored plans and does not apply to patients with Medicare Advantage or contracted Medicaid coverage with UnitedHealthcare, Lempner said. UnitedHealthcare in 2018 said it had more than 30 million Americans with commercial or employer-sponsored plans. “If the event is determined to not be an emergency, the claim will be paid based on the member’s benefits,” Lempner said, adding, “We estimate that nationally less than 10% of (Emergency Department) claims will be classified as non-emergent through this program.”

The policy will take effect in 34 states and the District of Columbia, Lempner said. They are: Alabama, Arizona, Arkansas, Colorado, Connecticut, Washington, D.C., Delaware, Florida, Georgia, Indiana, Iowa, Kansas, Kentucky, Louisiana, Maryland, Massachusetts, Michigan, Mississippi, Nebraska, Nevada, New Hampshire, New Jersey, New York, Ohio, Oklahoma, Oregon, Pennsylvania, South Carolina, Tennessee, Texas, Utah, Virginia, Washington, West Virginia and Wisconsin.

Read more: https://www.usatoday.com/story/news/health/2021/06/09/unitedhealthcare-policy-assess-er-claims-sticking-patients-bills/7629006002/

---

So now we get to fight with the insurance companies about emergency room visits too. This will be a boon for lawyers.

[Roy Rolling]

1. Of Course

Second-guessing is easy after the emergency.

UnitesHealthcare should be required to approve the visit when it happens. Let them make a real-time decision and see how complicated it is.

[diehardblue]

2. Time to reassess my supplemental health care carrier....

🤔

[jaxexpat]

6. And I'm sure you'll have plenty of company in that effort.

However, I'm suspecting when word gets out that United sees increased profits from this policy, there'll be many other carriers following that same path. You're reassessment will thus have a new dimension, identifying the insurer who's premium increase is the least onerous while retaining the current ER policy.

So long as the health insurance "industry" is a publicly tradeable "investment vehicle" the tension between profits and premiums will continue while coverage remains in constant flux. Trending downward, I'd say.

[vsrazdem]

33. If you have a supplemental, then likely you are on Medicare or Medicare Advantage.

This will not apply to you, but that doesn't make the situation any better. It just means they don't want to fight with the government about this.

[GregariousGroundhog]

40. My perception of United Healthcare is quite positive

My dad, my brother, and I have all used UHC at one point or another. My dad liked them, and I never had an issue in my interactions with them. Additionally, they helped by brother twice by lowering the boom on a hospital and a pharmacy that pulled some pretty shady crap.

[BComplex]

42. AARP (huge lobby) pushes United Health Care on medicare and over 50's people.

They need to DROP that idea and find another carrier to support.

[bucolic_frolic]

3. What about Urgent Care

I see many brands of urgent, or critical, care centers popping up. Some are tied to hospitals, some from insurers, some I just don't recognize. They've taken over every type of empty strip mall or small store, from 7-11s to rug store to former retail stores. Yes a convenience store became a taco shop for awhile, but now it's a full-fledged critical care center.

Why haven't these non-emergency urgent care centers been opened inside or beside the ERs? Oh, because ERs make too much money to properly sort the cases into ER and sort-of-ER.

And btw, drug store chains were supposed to have nurses, but in my area only a few have them. I think Walmart Pharmacy has soaked up all the business because they are quick and convenient.

[Snarkoleptic]

4. So we've found the "death panels" and they're in corporate board rooms!

We can't get to single-payer fast enough!

[Ferrets are Cool]

12. That's where they have always been

[dalton99a]

23. +1

[Hortensis]

68. All systems need to try to cut costs, and I believe you do want

better healthcare for less, right?

A universal single payer will be constantly working to control costs in order to cover everyone, but it'll be the government doing it, for better but also potentially much worse. See the "REALLY BIG ONE."

But, what will happen when people have no alternative but to accept the only game in town? When even changing employers won't make any difference? When there is NO competition? There are tradeoffs to everything.

And -- THIS IS A REALLY BIG ONE: when anti-government/anti-tax conservatives get control and gut the budget for a single payer system, providing only minimal care. We have elections every 2 years, you know, and a lot of ignorant voters who hear phrases like "death panels" and vote against. Because no one wants them, right?

Regarding calling controlling costs "death panels," it doesn't matter squat whether the accused death panel is corporate or government. In both cases those fooled end up supporting conservative extremism to fight the smart, good people fighting to make universal healthcare real. That's the whole point of the giant "death panel" lie in the first place.

[Deb]

5. Guess we have to pay for that Ransome attack. Call an ambulance or go to a walk in first.

Its like having a medical ER referral. Sad.

[Traildogbob]

7. Not surprised

UHC is one that hijacks old people’s real Medicare by offering their version of Government operated Medicare. They promise everything, ask Joe Namath, and when you file, they deny deny deny coverage. They predate on vulnerable seniors, and tell them forget that government insurance ya paid for all your life, we got something better, give us your premium.
Scammers of the worst kind.
Bet ya, they paid no taxes either.

[JohnSJ]

9. Are you referring to a Medicare Advantage Plan? If so, that is why people who sign up for an

Advantage plan verses a supplemental or medi-gap plan, need to carefully see what is covered and what isn’t

With some of these Medicare Advantage Plans, Part C, they might represent value if you are relatively healthy, but one accident or stroke can change all that.

It isn’t just UHC, a lot of advantage plans have inadequacies that a good number of people don’t realize until something happens

Also, the OP specifically says it will apply to the following:

“commercially insured patients with employer-sponsored plans and does not apply to patients with Medicare Advantage or contracted Medicaid coverage with UnitedHealthcare”

Namath only advertises for advantage plans

[Traildogbob]

36. Great heads up

Thanks. I have My Government Medicare and was sold by an advantage agent that this med advantage is free, earned and just additional coverage. Little did I know the policy over road my claims from basic Medicare. As A vet, when I use medical facility I must provide my additional insurance and the VA pays what my civilian does not. I did not know what Advantage was doing until I got notice from the VA that the Advantage has been denying everything and they would have to adjust my VA Medical coverage. I have BCBS State Retirement as well and they were concerned of advantage denials. When I tried to drop the Advantage policy they make it very hard. Would say I was back on my original, but would still get claims made to them with denial. Took 9 months to get shed of em. Just be careful and know what you are getting. Scammers are thick out there preying on seniors that can’t understand the whole mess about health care.

[JohnSJ]

37. It's too complicated

[Pinback]

54. Thanks. Still bad news for many of their policyholders. (nt)

[JohnSJ]

55. Yup

[SharonAnn]

66. They can change whatever they cover as time goes on.

If you have been on an Advantage plan, convert to standard medical with a supplemental as soon as you can.

Don’t trust any of these companies to keep their original “promises” or contracts.

[JohnSJ]

67. That is not entirely accurate. Except at the initial enrollment into Medicare, it is not

a given thing that they will be able to convert to a Medi-gap plan from an Advantage plan

When you switch from Medicare Advantage to Original Medicare, you lose your “guaranteed-issue” rights for Medigap.

You have guaranteed-issue rights for six months when you are 65 or older and enrolled in Medicare Part B. Guaranteed-issue rights ensure that you can buy any plan sold in your state, and that you won’t be charged higher premiums based on your health status.

Without guaranteed-issue rights, your insurance company may require medical underwriting before it sells you a plan. During medical underwriting, the insurer looks at your past medical history and current health status. If the company determines the risk of covering you is too high, it can refuse to sell you the plan you want, or it may charge you much higher premiums for the coverage.

[Casady1]

10. My insurance agent

advises against Medicare advantage exactly for those reasons. He told me he makes more money off of Medicare Advantage but has almost everyone get supplemental insurance. By the way Mutual of Omaha has the best rates.

[MOMFUDSKI]

14. My insurance guy

said stay with Advantage until and unless you have an ongoing health issue that would make it worth the many extra dollars per month one pays for a supp. And with Advantage one can switch at anytime to a supp should things go sideways. I switched out to a PPO Supp plan for 2 months so I could go to the eye doc I wanted to do my cataracts and then right back into my $9/month Advantage as did my husband just a few months ago. I DO have diabetes which gives me more latitude with the switching.

[JohnSJ]

18. You need to be careful because there are only certain times that can be done depending on the

state you live in.

Also, if you have a medical event that occurs while you are under a Medicare Advantage plan, I am not sure if you can just switch to a medi-gap plan for that condition

You need to see what the actual Medigap plan you want to switch too says, and if there are any restrictions

[Casady1]

27. My agent said

that when you switch back the insurance company has the right to underwrite you. There is the danger. Remember the agent makes more money off of you when you go on advantage. My sister in law husband's had major problems and the nurse a said if he was on advantage they would not have paid for his rehab. With Advantage you have all the restrictions and pitfalls of for profit insurance.

[JohnSJ]

15. The OP specifically applies to the following

commercially insured patients with employer-sponsored plans and does not apply to patients with Medicare Advantage or contracted Medicaid coverage with UnitedHealthcare

So supposedly it doesn’t apply to advantage plans, but I agree on your assessment, people have to be very careful what is and isn’t covered if they sign up for an advantage plan, or any plan for that matter

The best supplemental Medicare plans are supplemental F and G. Those plans also have the most expensive premiums

[Lonestarblue]

31. That's why I still have original Medicare, even though I have to pay for dental and vision.

I don’t think I’ve ever had any medical test or visit refused. Plus, I don’t need a referral if I want to see a dermatologist or other specialist. I did try Urgent Care once on a Sunday for what I thought was strep throat and they would not accept my insurance. I’ve forgotten now whether it was Medicare or my supplemental, which happens to be UHC.

[Vinca]

8. If you suspect you're having a heart attack and wait to be sure, it could be curtains for you.

If you leave a minor wound unattended an infection could land you in the hospital and cause UnitedHealthcare a million dollars. Big insurance does stupid, heartless things, but this one hurts not only the insured, but the insurer. Dumb, dumb, dumb.

[elias7]

24. Chest pain and wound care should typically be covered

[JohnSJ]

39. Yes, even if it turned out to be indigestion, I just don't see them denying coverage to anyone

exhibiting symptoms of a heart attack.

[Ferrets are Cool]

11. Who the hell goes to a crowded ER and sits for hours next to other sick people

BECAUSE THEY FUCKING WANT TO???????????????????????

[JohnSJ]

13. Those that don't have a primary care physician. The OP says 1 out of 10, it applies to the

following:

“commercially insured patients with employer-sponsored plans and does not apply to patients with Medicare Advantage or contracted Medicaid coverage with UnitedHealthcare”

[elias7]

25. You'd be surprised

Our rural hospital does not have people sitting for hours next to sick people. People get their own exam room with minimal to no waiting in the waiting room.

People come in for week(s) long history of this or that and kind of hit critical mass, deciding that “now is the time to be seen and I can’t wait another minute”, typically state that they called their doctor and could not get in right away, or their doctor’s office didn’t call back, or that they could not sleep… so they come in with a subacute problem.

Thing is, they’ll get a better workup for a lot of things in the ER because we’ll do bloodwork, x-rays, follow-up studies all in a few hours. But this is stuff that would have been ordered anyway as an outpatient over days perhaps. So the only rationale that a payer would have to deny a claim is if the person got tests or care that they would not have needed for workup of this problem, which is typically not the case.

I think it reasonable to deny a small part of the charges for some ER care, but for the most part, insurance companies shouldn’t weasel out of costs that would have been incurred one way or another in the evaluation of a problem.

[Ms. Toad]

30. A ton do.

It is the one place you cannot immediately be turned away for lack of money. Way too many people don't have access to primary care and use the ER essentially as primary care for serious, but non-emergency situations.

It is a legitimate concern - BUT - the way to address it is to make primary care more accessible, not attack a retroactive tax on those who have no other options.

[IronLionZion]

34. Many reasons

if their primary care physician is unavailable for an immediate appointment or it's during off hours. If the patient doesn't know what is the problem but it feels like an emergency. Plenty of people don't know the difference between primary care, urgent care, and emergency care so the ER is often their default stop.

Perception vs reality is a big problem. If a person is having a legit life threatening emergency, they shouldn't hesitate about going to the ER. For other problems they should be able to go to urgent care or primary care or call their doctor's office to ask what to do. This process should be simpler if we had a universal single payer health care system instead of lots of different plans and providers having different processes and criteria and networks.

[moriah]

43. I'm the opposite of "ER happy".

Every time I've ever gone to an urgent care because my PCP couldn't see me fast enough, I've been sent to the ER. And at least in the last eight years, each ER visit (whether referred by urgent care or not) has resulted in admission.

Also, since while patients do suffer from insurers rejecting claims, hospitals suffer more. This is more likely to encourage ERs to have an onsite urgent care clinic, do triage, and send "non-emergencies" to that side of the house. Which isn't a bad idea for ERs large enough to do it, but will really hurt small ERs.

Finally, I want to make sure they consider prescribing antibiotics for a bad tooth in their definition of "emergency". A guy I knew had gotten back home from working on the road and was waiting for the check, and his tooth had been bad a minute. He went to the ER and they refused to see him at all for a tooth problem, even to just script him some Pen VK and ship him out. He lived alone, and his dad was the one to find him dead alone -- it was an upper tooth, and the abscess penetrated deep. There was some evidence he attempted to try to get dressed in his delirium to perhaps walk over to a neighbor's house for help, but this was before that area had much cell coverage, and he didn't have a land line to call 911.

[Ferrets are Cool]

47. I guess y'all missed the body of my post

ECAUSE THEY FUCKING WANT TO???????????????????????

It's ONLY when they MUST. Sheesh

[AllyCat]

16. United Healthcare is practicing medicine without a license again

They are the worst. How many houses does their CEO have, again? I cannot keep track.

[RicROC]

17. $18.9 Millions compensation for CEO

That's what the CEO of United Healthcare made last year. Other sources say it's closer to $52 Million

[LittleGirl]

19. Why have insurance when they refuse to pay?

Seriously, Medicare for all.

[Ingersollman]

20. Two

words:
Single Payer

[area51]

28. +1

It's crazy to pay the amount of taxes we do, but not get healthcare in return on investment.

[JT45242]

21. Guess how many of those states have an R for governor or legislature

Overuse of emergency rooms instead of normal care us very expensive and a waste if resources. But no coverage seems like trying to screw people, especially old people who have been taught that emergency rooms are good to use if you have any symptoms that could be stroke or heart attack.

My policy has crazy high copay if I go to ER and don't get admitted that seems like enough of a deterrent to keep people from using the ER as primary care

[Sin]

22. Just going to drop this here for people who need it.

https://imgur.com/gallery/Sw6gYc7?fbclid=IwAR2VXvYFhLz3lTs48Nj_PkyZpm6iziTPG_prp-E2LqxaoJpo5115NwsGuTI

[EarthFirst]

52. +1

I’ll share this in my social network; thanks.

[ShazamIam]

26. For profit only health insurance is madness. nt

*typo edit.

[Hoyt]

29. Insurance companies, even Medicare, have tried to control emergency room care for decades.

Emergency Rooms are a very expensive site for care that could be handled better by primary care.

[Ms. Toad]

32. Combined with the pain medication-in-a-lockbox policies this will be disastrous.

My spouse has kidney stones - repeatedly. If you've had one, you know the pain can be disabling - it is that intense. AND - the standard advive - is to wait and see if it will pass.

Her urologist NEVER has an appointment sooner than 2 weeks out. He can call in a prescription for FLOMAX (designed to increase urine output to encourage the stone to pass itself). BUT to get a prescription for pain meds he has to physically see her.

His advice: Go to the ER. They can give her a prescription for pain meds to hold her until she can see him.

BUT - this is not a medical emergency. We all know what she has. Aside from pain, it's not gonna kill her. We all know that he will ultimately have to blast it out. But we have to walk through the steps to get there - which include living with the pain for 2 weeks. Or going to the ER for pain meds.

Fortunately this is not our insurance provider. But, if it was, I would expect them to deny coverage for her visit because it really isn't a medical emergency. It is a policy emergency (necessary only because the powers that be decided to solve drug addiction on the backs of those in chronic or acute pain. Bottom line - acute pain, with a known source, is something that should be handled in a doctor's office (or by a phone call to the pharmacy). Not an emergency room visit.

[Jedi Guy]

50. I've had several kidney stones, so I can sympathize with your partner.

I have a pretty high pain tolerance, but even so it's excruciating, screaming-through-clenched-teeth painful when it hits hard. When I got the first one, I sat in the ER waiting room for nearly 10 hours because, while I was in a horrific amount of pain, I wasn't in life-threatening danger. Not exactly a fond memory.

[Marrah_Goodman]

58. Unfortunately because of addicts it very hard to ever get pain meds here

Had surgery on my hand in two places. I recovered on tylenol which did nothing to help the pain.

[Elessar Zappa]

65. They didn't give you opiates after surgery?

That’s crazy!

[Marrah_Goodman]

72. Nope!

[DallasNE]

35. Still Another Reason To Move To Single Payer nt

[Orrex]

38. Insurance has done shit like this for years

My wife needed an MRI a few years back. Insurance said they’d determine whether to cover it based on the results, so we’d have no way to tell if her doctor-prescribed test was going to cost $25 or $1400.

How is the patient, the purported “healthcare consumer,” supposed to make an informed purchasing choice when it is impossible to shop around or to know the cost prior to purchase?

[csziggy]

49. Yes - in Jan. 2017 my cardiologist prescribed a CT scan to diagnose my heart problem

I was on an ACA Blue Cross/Blue Shield policy at the time. They delayed and delayed. I had an appointment for late June, finally, but still did not have BC/BS approval for payment. When I realized I was moving to Medicare with a really good supplemental policy on July 1, I changed the appointment to the beginning of July. Two days after I got the CT scan, I got a letter of approval from BC/CS for the original appointment date.

I was lucky to be at that cusp - at the rate BC/BS was moving, I would not gotten my heart valve diagnosed for years - and as a consequence, the kidney cancer that was found along the way would not have been discovered before it grew and spread.

[Marthe48]

41. If I called my dr. I was told to go to e.r.

It didn't matter if the dr.'s office was open or closed. Didn't matter if urgent care office was open or closed. It didn't matter if I had a back spasm or my husband was sick from chemo. Go to e.r. Once there, we were told if we got admitted, our ins. would pay for e.r. or we'd just have a $50 copay.

I think that whoever I speak to in a dr's office doesn't want to diagnose over the phone and possibly run into a lawsuit. After all, sometimes a sore toe is way more than a sore toe.

Another thing, I had a matter I wanted to see my dr. (a nurse practitioner) about which was somewhat urgent. The clerk in the office said I wouldn't be able to see her for almost 3 weeks. I have to schedule a well-care visit months ahead. I haven't seen the dr. in the partnership for years. I gave up on his accessibility years ago. I like the nurse prac. and get good care and diagnostics from her.

[seta1950]

44. Frankly

Trusting the insurance industry, over and over when we all know they don’t care about people’s health, but their own profits is utter stupidity, we will keep failing and people suffer.

[DavidDvorkin]

45. On the bright side, unlike other countries, we don't have government bureacrats gettting between us

and our doctors.

[mdbl]

60. You mean like in post 49 above?

[DavidDvorkin]

62. I hope it was clear that I was being sarcastic.

[mdbl]

64. It wasn't clear to me but I made that assumption

[Javaman]

46. I wonder when this will spread through the rest of the industry...

yes, in this country, healthcare insurance is an industry run on profits and little to no thought about the patients.

expand medicare, single payer, or something else. anything but this fascist form of health insurance we currently have.

[ruet]

48. "We estimate that nationally less than 10% of (Emergency Department) claims will be classified as...

...non-emergent through this program.”

If you believe that; I have an insurance policy to sell you.

[Jedi Guy]

51. Discouraging people from going to the ER unnecessarily isn't a terrible idea.

When people show up to the ER with something that's obviously not an emergency, it bogs things down for everyone.

However, this is not the way to go about accomplishing that goal. This is going to result in a lot of people getting hit with big medical bills. Even worse, I'm sure a fair number of people will forego getting care out of fear of not being able to afford it, only to find out later that they have a condition that could have been treated much more easily if it had been caught earlier.

[CTyankee]

63. Some people just may not know what is a true emergency and what can wait.

Obviously if you have a deep cut from trying to slice through your Sunday morning bagel you can sorta tell if it's necessary. But some people may have the early onset of heart disease and it's bothersome but not a real heart attack. I see commercials about not waiting to go to the ER if you have chest pain, etc.

We have a walk in clinic near our house but it is tiny and sometimes the wait is really long because only one doctor (who owns the clinic) works there and a staff of two, a nurse and a receptionist. The nurse does this prelim exam that includes bp and heart rate.

[FlyingPiggy]

53. this is reckless but typical of corporate mentality. penny wise and pound foolish.

they'll save 17 million a year and pay out 57 million in lawsuits. There are just too many look alike symptoms that can be either benign or lethal. SMDH....

[live love laugh]

56. It seems to be red states doing this. nt

[Mosby]

57. I think this has already been happening.

I had an emergency appendectomy last year, went to a hospital ER per my PCP. The first letter I got from Aetna was to tell me that they accepted the medical reasons for my admission via the ER. Thought it was weird at the time, but obviously had they not accepted the reason, they would not have covered that portion of the bill.

[Sapient Donkey]

59. I wonder how that will work in practice. About 10 years ago I went to the ER

when I woke up extremely dizzy and could barely walk without stumbling over. Additionally, that brought on what I believe was a panic attack. Which at the time was something I never experienced before. I thought I was dying and ended up in the ER. It ultimately turned out to be that pesky sinus infection I ignored, and wasn't something like a stroke or whatever. I can imagine in a situation like that they would say "oh it wasn't really an emergency", or at least they would attempt to pull something like that.

[MineralMan]

61. If there were more urgent care clinics, many ER visits wouldn't be necessary.

The problem is that many areas just don't have them readily available for patients. The insurance companies are pretending that everyone has such a clinic nearby they can go to for immediate care. That's just not true. So, people head to the ER for things that could be handled in an urgent care clinic. They really have no choice.

Also, most people are not qualified to decide whether they are having an actual medical emergency or something that can be handled in a less capable facility. There are nurse lines for most insurance, but how many people know the phone number of that nurse line? Most do not, but they know where the nearest ER is.

[Hortensis]

69. Well, urgent cares and walk-in clinics have become a lot more numerous

than hospital ERs, almost everywhere -- and surely are just as easy to find the second time?

Problem is they're not necessarily open 24/7 (8-8 most days is common) and most ERs are. I'm permanently outraged that large medical practices don't provide some practitioners to their patients on weekends. Two days of every week established patients are expected to seek medical care from strangers.

[Hortensis]

70. There are problems to be fixed, but I'm with the nasty corporate death panel on this.

Let's face it, the hundreds of thousands who go to enormously expensive ERs for a sore throat or diarrhea, to get a cream for poison ivy or finally have a boil lanced, etc, know it's not an emergency , and those visits are the ones this is about.

Maintaining a very high level of care 24/7/365 for low-level needs has always been a serious problem that drives up medical costs tremendously. Further, it too often delays care and limits resources available for those who do arrive with the serious issues ERs are maintained for.

[BadGimp]

71. What could possibly go wrong?

A person avoids an Emergency Room visit over some kind of Heart issue and then dies a day or so later as a result.