February 26, 2018

Luján Questions CEO of UnitedHealth Group Over Refusal to Cover Emergency Room Visits for Some Patients

[WASHINGTON, DC] –Congressman Ben Ray Luján (D-NM) this week sent a letter to the CEO of one of the nation’s largest insurance companies, UnitedHealth Group. to inquire about his company’s policy of declining to cover emergency room visits that UnitedHealth determines to be “non-emergent” after the fact.  

Health advocates have expressed concern about the policy that UnitedHealth and other insures have adopted regarding emergency room visits.  Under these policies, UnitedHealth will review diagnoses after members' emergency room visits. If the condition is determined to be “non-emergent” by the insurance carrier, UnitedHealth may not cover the ER visit. Such denials could cost patients thousands of dollars for trying to obtain medical care and could cause people to refrain from seeking needed emergency care.

In his letter, Luján wrote:

“Under most circumstances, patients cannot be expected to determine whether their symptoms are due to an emergent or non-emergent condition.  According to a study in the Journal of American Medical Association (JAMA) in 2013, there was an almost 90% of overlap between ‘primary care treatable diagnoses’ (or non-emergent) and ‘emergent’ chief complaints.  Only 6.3% of visits were determined to be ‘primary care treatable diagnoses’. Further, the Center for Disease Control (CDC) has found that only 4.3% of ER visits are because of non-urgent symptoms. This raises serious concerns that UnitedHealth’s policy could have the dangerous consequence of depriving patients of needed care or discouraging patients from seeking treatment for emergent conditions.”

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[full text of letter is below]

 

February 22, 2018

Mr. David Whichmann

Chief Executive Officer

UnitedHealth Group Center

9900 Bren Road East

Minnetonka, Minnesota 55345

 

Dear Mr. Whichmann,

I am writing to seek additional information and raise concerns regarding UnitedHealth’s policy of declining to cover emergency department visits that UnitedHealth retroactively determines to be non-emergent.  I understand that emergency room visits come at a higher cost for both carrier and beneficiary and that it is important to ensure appropriate emergency department use.  However, I am deeply concerned that these policies will deter people across the country from seeking emergency care for emergent conditions out of fear of an unaffordable bill.  

Under most circumstances, patients cannot be expected to determine whether their symptoms are due to an emergent or non-emergent condition.  According to a study in the Journal of American Medical Association (JAMA) in 2013, there was an almost 90% of overlap between ‘primary care treatable diagnoses’ (or non-emergent) and ‘emergent’ chief complaints.  Only 6.3% of visits were determined to be ‘primary care treatable diagnoses’. Further, the Center for Disease Control (CDC) has found that only 4.3% of ER visits are because of non-urgent symptoms. This raises serious concerns that UnitedHealth’s policy could have the dangerous consequence of depriving patients of needed care or discouraging patients from seeking treatment for emergent conditions.

I am particularly concerned about the impact these policies are having, and will continue to have, on pediatric patients. Recently, a case came to my attention where a mother brought her two-month old son to the emergency department because he was struggling to breathe. However, the claim seems to have been denied because the baby was breathing by the time they arrived in the emergency room. According to information I have received from your company, UnitedHealth appears to have denied this appeal.  

As you know, children are unable to communicate symptoms in the same manner as adults. Under what circumstances do we expect parents to make potential life-altering decisions about seeking emergent care for their children? 

I ask that you answer the below questions. Given that such claims are actively being denied, I respectfully request a response by March 1, 2018. 

Sincerely, 

 

Ben Ray Lujan

Member of Congress

  1. Why did UnitedHealth decide to pursue the practice of not covering emergency department visits later determined to be non-emergent through a medical review process? When was this policy implemented?
  2. What UnitedHealth plans does this affect? Employer Sponsored Insurance (ESI), healthcare marketplace, Medicaid Managed Care, etc?
  3. What percentage of your beneficiaries have non-emergent, Emergency Department claims? How has this changed since UnitedHealth enacted this policy? 
  4. How does UnitedHealth determine that a patient’s ED visit was non-emergent?  Does the company request and review the entire medical record, or just the claims? How does this differ for adults and pediatric patients?  Are pediatric claims exempt from the medical review?
  5. Can you explain how UnitedHealth’s policy does not violate the Prudent Layperson Standard (PLS), which requires health insurance plans to base reimbursement for emergency services based on the presenting/Chief complaint and not the final diagnosis? How does UnitedHealth’s interpretation of PLS differ for adults and pediatrics?
  6. What DRGs or Hierarchical Condition Codes are included in UnitedHealth list of non-emergent conditions? Does this differ for adults and pediatric cases? 
  7. Is this a nation-wide UnitedHealth policy or are only certain states involved? 
  8. Who reviews these claims and makes the final decision regarding coverage? What specialties are the physicians who serve as medical directors that perform the review of non-emergent, emergency department claims? Are all UnitedHealth’s medical directors board-certified physicians? Are there mid-level providers and BSN-level nurses serving in these roles? Are all pediatric cases reviewed by a pediatrician?
  9. Please provide further details on the amount of emergency department and/or emergency medical services claims UnitedHealth receives for each state where this practice has been implemented. Provide further detail on the number and percentage of ED claims flagged for non-emergent use, non-emergent claims denied, the number and percentage of appeals United receives for denial of coverage for non-emergent claims, and successful appeals.