FinancialHospitalsRegulatory

UnitedHealthcare looks to retroactively deny emergency room claims

The policy is an attempt to curb healthcare costs, but some providers are worried it could lead to lower reimbursement.

June 8, 2021 / Jeff Lagasse, Associate Editor

UnitedHealthcare is re-examining its policy on emergency department visits, and is now evaluating ED claims to determine if the visits were truly necessary for commercially insured members, the nation’s largest insurer recently revealed in a notice on its website.

Claims that are deemed non-emergent — meaning not a true emergency — will be subject to “no coverage or limited coverage” beginning on July 1, UnitedHealthcare said. To determine whether this is the case, the insurer will evaluate ED claims based on factors including the patient’s presenting problem, the intensity of diagnostic services performed and other criteria.

If an ED event is determined to be non-emergent, there will be the opportunity for attestation, which will be sent electronically to the facility in question. If processed in the required timeframe, the claim will be processed according to the plan’s emergency benefits.

This means the amount paid by UnitedHealthcare may be less for incidents it determines are non-emergent.

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Josh Sandberg

Josh Sandberg is the President and CEO of Ortho Spine Partners and sits on several company and industry related Boards. He also is the Creator and Editor of OrthoSpineNews.

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