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The American Hospital Association (“AHA”) has sent a strongly worded letter to UnitedHealthcare protesting a recently announced policy that would allow United to deny all or part of a patient’s treatment in a hospital’s emergency department if United determines that the patient was treated for a non-emergent condition.

Under the policy, United would retroactively review all claims for services provided in a hospital’s emergency department, evaluating the patient’s presenting problem, the intensity of diagnostic services performed, and other patient complicating factors and external causes. In a communication sent to providers, United stated: “Claims determined to be non-emergent would be subject to limited coverage or may not be covered for the full cost of the emergency room visit.” The policy is set to take effect for fully-insured commercial members on July 1, 2021.

In a June 8, 2021 letter to United’s CEO, AHA expressed its deep concern over the policy and urged United to reverse it immediately. In support of this request, the letter stated:

Patients are not medical experts and should not be expected to self-diagnose during what they believe is a medical emergency. Threatening patients with a financial penalty for making the wrong decision could have a chilling effect on seeking emergency care. This is dangerous for patients’ health at any time, but it is particularly unsafe in the midst of a public health emergency. Deferred and delayed care during the pandemic has already contributed to adverse health conditions and increased acuity. This is exactly why federal law requires insurers to adhere to the prudent layperson standard, which prohibits insurers from putting up coverage roadblocks to emergency services, such as by determining retroactively whether a service will be covered based on the patient’s final diagnosis.

(emphasis in the original)

If United doesn’t agree to reverse the policy, the AHA letter asked United to agree in writing that it would cover the emergency services if a facility attests that a case meets the prudent lawperson standard.

Lastly, the letter questioned United’s claims that any savings achieved would accrue to consumer in light of United’s continued increase in premium prices over the last several years despite policies that restrict coverage and in light of UnitedHeatlh Group’s robust profits, which include a 35% year-over-year increase in the first quarter of 2021.

The AHA letter is linked here.