Major Insurer Moves To Deny Some Emergency Room Claims

UnitedHealthcare, the country’s largest health insurance company, is looking to crack down on unnecessary emergency room visits with a new policy, which was originally set to go into effect on July 1st. The insurance carrier is planning to begin scrutinizing all emergency room claims to determine if they are actually medical emergencies; if these claims are found not to be true medical emergencies, the claims will either be denied, or covered on a limited basis, depending on the patient’s insurance plan. However, because the company has received backlash from doctors, hospitals, and the American Hospital Association (AHA), UnitedHealthcare released a statement on June 10th, saying that they will postpone the new policy until the end of the pandemic. So, what can policyholders expect in the future when it comes to emergency room coverage?

Why UnitedHealth Postponed The Policy

illustration of people with masks on being seen by doctors
Doctors and hospitals are condemning UnitedHealthcare for the new policy, especially during a pandemic.

The American College of Emergency Physicians have been pushing back against the new policy,  pointing out that the change could mean patients will avoid going to the emergency room for fear of large hospital bills. Doctors and hospitals are especially worried that people with true emergencies, such as a heart attack, will not go to the hospital, which could result in serious damage, or even death. They also worry because many serious conditions have symptoms that overlap with less serious conditions, and patients need to be able to seek emergency care for diagnosis. 

Because of the controversy surrounding the new policy, which seems especially poorly-timed during a pandemic, the Minnesota-based health insurance company has decided to postpone the policy until the pandemic is over. 

“Based on feedback from our provider partners and discussions with medical societies, we have decided to delay the implementation of our emergency department policy until at least the end of the national public health emergency period,” Tracey Lempner, spokeswoman for the Minnesota-based insurer, said in a statement. “We will use this time to continue to educate consumers, customers, and providers on the new policy and help ensure that people visit an appropriate site of service for non-emergency care needs.”

What Customers Should Expect

One of the reasons UnitedHealthcare wants to crack down on emergency room claims is that hospitals charge more for procedures performed at a hospital as compared to procedures performed in other settings, and they feel that customers are using these expensive services unnecessarily. In fact, based on data from the UnitedHealth Group, UnitedHealthcare’s parent company, emergency department misuse costs the U.S. healthcare system roughly $32 billion annually. The insurer would prefer that as many less serious issues as possible be handled in a non-hospital setting, which would cost the company and patients less. 

“We are taking steps to make care more affordable, encouraging people who do not have a health care emergency to seek treatment in a more appropriate setting, such as an urgent care center,” Lempner said.

large medical bill with a credit card and pen on top of the bill.
If the emergency room claim is denied, then patients will have to pay for the bill out of pocket.

So how will the new policy work and what will its effect on patients be? According to UnitedHealthcare, they will not apply the new policy to those with Medicare Advantage plans or contracted Medicaid coverage, but it will apply to everyone else, including employer-sponsored plans. The only other exceptions are for children under 2 years old, and observation stays. The company will evaluate emergency room claims based on the patient’s medical concern, the intensity of diagnostic services performed, and other patient complicating factors. 

It is projected that as many as 1 in 10 claims could be rejected under this new policy, but there is an appeals process. If a claim is denied, the hospital can submit evidence that the visit met the definition of an emergency consistent with the prudent layperson standard, which requires insurance companies to provide coverage for emergency care based on symptoms, not the final diagnosis.

“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] claims will be classified as non-emergent through this program.”

When the pandemic is over, the policy will take effect in 34 states and the District of Columbia: 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.

Don’t Wait! Start An Emergency Fund Today

If the COVID-19 pandemic has taught us anything, it’s that sometimes the unexpected happens. Unfortunately, has also taught many families that they are financially underprepared for a crisis. In 2019, research by the Federal Reserve revealed that 22% of Americans regularly expect to forgo or make late payments on some of their bills. In fact, 40% of Americans can’t afford a $400 emergency. Many of us are that close to financial danger. That’s one veterinarian’s bill, two flat tires, or a few days of missed work. caucasian man and woman sitting on a couch looking worried with a piece of paper in the womans hand

Financial insecurity means more than overdue bills and missed payments. Debt causes stress that can have pretty drastic physical and psychological repercussions. If you are worried about your financial future, or if you feel like you’re in dire straits right now, know that it’s not too late to turn things around. We’ve compiled some financial tips and tricks from the experts to get you on the road to rebuilding your savings account and starting an emergency fund. 

The Physical Side of Stress

If financial issues have you feeling overwhelmed, you’re not alone: 62% of adults report often feeling stressed about money. That stress can wreak havoc on our bodies. Considering that American debt has increased by a whopping 300% since the 1980s, is it a coincidence that we are also experiencing higher rates of chronic diseases? Experts have mixed opinions, but there is some speculation that the amount of stress Americans are under is the culprit, along with other systemic, environmental, and psychological factors. For example, high levels of stress   are associated with:

blood pressure machine with a weekly pack of pills in front of it
Being stressed out can lead to high blood pressure , which can lead to other serious health conditions with your heart.
  • High blood pressure. Often linked to heart attacks, strokes, and a myriad of other health issues, high blood pressure can be triggered by stress. This could be due to the body’s overproduction of stress hormones like cortisol, or due to poor coping mechanisms like binging on snacks. 
  • Diabetes. Evidence suggests that chronic stress can increase the risk of diabetes in adults. To make matters worse, financial uncertainty can limit a person’s access to healthy foods and time or ability to exercise, which can further add to the problem. Evidence also suggests a link between a family’s financial struggles and the incidence of type 1 diabetes in children.
  • Digestive issues. There is a well documented connection between stress and gastrointestinal issues. When under heavy financial stress, many don’t follow regular eating habits. Healthy food may not even be accessible or affordable for those in financial trouble. In addition, 27% of people with high debt stress reported having ulcers or other digestive tract problems, compared to just 8% who did not report high levels of financial-related stress.
  • Muscle tension. Over half of all people who experience high debt stress report muscle tension and back pain. When you’re worried about supporting yourself, or your family, it really can feel like you’re “carrying the weight of the world on your shoulders”. To help relieve these symptoms, consider simple stretching and de-stressing exercises

Of course, it doesn’t help that people who are under financial stress often avoid seeing the doctor out of fear of medical bills. In fact, 1 in 5 people say they have skipped or have considered skipping a routine or sick visit to the doctor’s office. This is understandable, considering that 56 million Americans have difficulties paying their medical bills – just one of the many reasons to work on building an emergency fund! 

Turn It Around Today! 

It’s not too late to take steps towards lightening your financial load. The best way to start is by saving for an emergency fund. Having money put aside can grant you some peace of mind: you’ll know that your expenses would be covered for a while should you lose your job or become unable to work, or that you would be able to cover a surprise expense, like a large medical bill or automotive repairs. Some financial experts suggest squirreling away three to six months of expenses in an emergency fund that you can access if you need it – so, not in an IRA or 401k account. For some people, three to six months worth of expenses is an unimaginable amount of money, so start with these five small, but meaningful steps:

  • Learn about the cycles and struggles of debt. Understanding how debt compounds and impacts your psychological and physical wellbeing is the first step to breaking out of that cycle.

    pink piggy bank standing on top of some money
    Reevaluate your budget and begin saving money so you can be prepared for the worst.
  • Re-evaluate your budget. Nothing in life is constant, so it is important to evaluate your budget regularly. Turning to auto-payments is a great place to start, and reduces the risk of late fees.
  • Pay yourself first. Treat your savings account like a bill, and pay it. Some people deposit a percentage or a flat amount of each paycheck, others deposit monthly. Whatever schedule works for you, stick with it! 
  • Turn your savings into profit. Make sure you’ve got your savings funds in an account that accrues interest. It might not add up to much – the average return for most bank accounts right now is between around 0.3% and 0.8% –  but every bit counts! 
  • Turn your debt into savings. After you pay off a debt, continue budgeting for it – but, instead of funneling money into that debt, use it to overpay on another balance owed;  otherwise, put it right into your savings account. 

You’re not alone in feeling overwhelmed by the stress of debt and the fear of unexpected financial crises. Digging yourself out of debt is hard, but with some simple changes you can get back on track. And doing so, even with baby steps, will help to ease your mind and support your good health.