Hospitals Wave Red Flags as UnitedHealthcare ED Policy Takes Effect

UnitedHealthcare (UHC) just launched a new protocol for evaluating emergency room claims that it says will encourage accurate coding by providers and ultimately bring down healthcare costs. Some hospitals view it as just another way to deny claims, however—and one that could actually end up costing patients more money, at that. Under the policy that took effect on March 1, UHC reviews and maintains the right to adjust or deny claims for ED visits coded at Level 4 or Level 5 for patients covered through United’s commercial and Medicare Advantage plans. Claims for ED patients who are admitted to the hospital, critical care patients, patients under 2 years of age, and patients who die in the ED will be exempt. The company claims the practice will not affect patients’ cost-sharing. As reported in Modern Healthcare, however, some hospitals say if a claim is denied, patients could be billed the entire cost of the visit. Other critics of UHC’s plan suggest that the appeals process could be challenging and time-consuming for providers who do not know the details of the insurer’s algorithm for assessing codes. Anthem has been roundly criticized for a similar policy.