June 17, 2021
Based on concerns from numerous medical societies and physician organizations, UnitedHealthcare (UHC) has delayed the rollout of a its planned emergency department facility review program. The new program, originally scheduled for implementation on July 1, 2021, would have implemented a post-service review of emergency department (ED) facility claims for commercial enrollees to determine if the visit was emergent in nature.
According to UHC the rollout has been delayed at least until the conclusion of the national public health emergency period.
Under the new ED facility review program, claims determined to be non-emergent in nature, coverage could be denied retroactively based on numerous factors including the following:
- The patient’s presenting problem
- The intensity of diagnostic services performed
- Other patient complicating factors and external causes
Claims determined to be non-emergent would be subject to a “no coverage” or “limited coverage” outcome depending on the enrollee’s benefit plan. Providers wishing to dispute the non-emergent determination would be required to submit an attestation that the visit met the definition of an emergency consistent with the prudent layperson standard. However, UHC reserves the right to still request medical records for claims review, even if an attestation had been submitted.
The California Medical Association (CMA) along with many other state and specialty societies, signed on to an American College of Emergency Physicians letter expressing grave concerns about the retroactive denial of coverage for emergency care. While CMA appreciates the temporary delay in implementing this program, we are urging UnitedHealthcare to rescind it permanently, and believe there is a better way to ensure that patients access the right care, in the right place, at the right time.
For questions regarding the new program, contact UHC Provider Services at (877) 842-3210.