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4 Reasons Why Unitedhealthcare’s Attempt to ‘Monday Morning Quarterback’ Ed Claims Is ‘Bad Policy’

UnitedHealthcare’s attempt to “Monday morning quarterback” emergency room visits by retroactively denying emergency claims is not only likely a violation of the prudent layperson standard, but also “bad policy” for several reasons, says Doug Wolfe, co-founder and partner of the Miami-based law firm Wolfe Pincavage.

“It really undermines what the physicians are doing at the point of care, and it’s bad policy,” Wolfe says on the newest episode of the HealthLeaders Revenue Cycle Podcast. “That’s why I think that’s a delayed implementation of this, because they recognized that it was going to be problematic.”

After its decision to delay the policy until at least after the COVID-19 pandemic, UnitedHealthcare told HealthLeaders in a statement that, “We will use this time to continue to educate consumers, customers, and providers on the new program and help ensure that people visit an appropriate site of service for non-emergency care needs.”

The onus is on payers to provide such education, Wolfe says. In the following excerpts from HealthLeaders’ conversation with him, Wolfe details four key points for revenue cycle leaders to know about this issue. They have been lightly edited for clarity and length.

To listen to the full interview, including Wolfe’s updates about legal action in similar cases, check out this month’s HealthLeaders Revenue Cycle Podcast.

    “There’s not one specific prudent layperson statute. Really, where it’s found is in definitions of emergency medical conditions in different states, and some other federal regulations and various laws that cover coverage for emergency treatment.

[For example] in Florida, there’s language on the books that the determination of an emergency medical condition is made by the attending or the treating physician at the time that the patient presents to the emergency department.

Emergency care isn’t just [that a] person has an emergency medical condition, and we need to fix it. The emergency treatment includes determining whether there’s an emergency condition in the first place. Until you know what it is, until you do that diagnostic workup, you can’t be sure to rule out some sort of a serious medical condition. So, the doctor that’s treating the patient at the point of service is in the best position to evaluate.”

    “If UnitedHealthcare’s worried about the cost of care, they should be educating their members in helping them understand where they can get more efficient convenient, cost-effective care. I think the onus is on the insurance company to educate the members on how they’re utilizing healthcare services.

If the claim gets denied, most of the time that turns into bad debt, and it’s going be hard to collect from the patient. And so, you’re punishing the hospital, and they’re not the ones that are making the decision on whether or not to go to the emergency room.

So, the policy is kind of disconnected from the incentive or the person that they’re incentivizing. [The hospital] is not the decision maker, so it doesn’t seem like it would be an effective mechanism to change their members’ behaviors and to help people consume healthcare in a more cost-effective manner.”

    “One of the things that we’re seeing specifically with UnitedHealthcare—and this is just anecdotal—but based on my experience and seeing the way that they’re drafting a lot of their policy, it appears to me that they may be using their health plans, policies, and procedures to steer patients to medical facilities that [OptumHealth] owns [such as MedExpress]. [Editor’s note: Optum is part of the UnitedHealth Group, and MedExpress joined Optum’s clinical service offerings in 2015.]

So, if Optum puts pressure on people not to go to the ER, but to use urgent care centers instead, it’s going to drive more patients to places that they own … it keeps everything within the UnitedHealthcare ecosystem.

Hospitals are competing with UnitedHealthcare from the Optum provider locations, but the hospitals do not have the same power to direct patients through coverage determination. It is very bad for hospitals, because it’s a competition issue and frankly, they can’t compete because they’re not set up to steer patients here or there because they’re not the insurance company.”

    Part of the pushback from the providers … is that low-acuity ER visits are not [causing] the high cost for healthcare. You’re directing people to places that aren’t set up to treat serious conditions [and] if they do exist … you have the urgent care visit, the ambulance transport, and then you have the ER visit on the back end. It would have been a lot cheaper if they just went to the ER in the first place. So, the economics of the policy don’t make a lot of sense when you look at it in the aggregate.

To listen to the full interview, including Wolfe’s updates about legal action in similar cases, check out this month’s HealthLeaders Revenue Cycle Podcast.

Alexandra Wilson Pecci is an editor for HealthLeaders.