UnitedHealthcare delays rollout of emergency department facility review program

CALAAEM News Service calaaem.news.service at gmail.com
Fri Jun 18 11:37:09 PDT 2021



 

June 17, 2021

 

UnitedHealthcare delays rollout of emergency department facility review
program

 

 
<https://www.cmadocs.org/newsroom/news/view/ArticleId/49392/UnitedHealthcare
-delays-rollout-of-emergency-department-facility-review-program> CMA

 

Based on concerns from numerous medical societies and physician
organizations, UnitedHealthcare (UHC) has delayed the rollout of a its
planned emergency department facility review program. The new
<https://www.uhcprovider.com/en/resource-library/news/2021-network-bulletin-
featured-articles/0621-ed-facility-commercial-claims.html> program,
originally scheduled for implementation on July 1, 2021, would have
implemented a post-service review of emergency department (ED) facility
claims for commercial enrollees to determine if the visit was emergent in
nature.

 

According to UHC the rollout has been delayed at least until the conclusion
of the national public health emergency period.

 

Under the new ED facility review program, claims determined to be
non-emergent in nature, coverage could be denied retroactively based on
numerous factors including the following:

*	The patient's presenting problem
*	The intensity of diagnostic services performed
*	Other patient complicating factors and external causes

 

Claims determined to be non-emergent would be subject to a "no coverage" or
"limited coverage" outcome depending on the enrollee's benefit plan.
Providers wishing to dispute the non-emergent determination would be
required to submit an attestation that the visit met the definition of an
emergency consistent with the prudent layperson standard. However, UHC
reserves the right to still request medical records for claims review, even
if an attestation had been submitted.

 

The California Medical Association (CMA) along with many other state and
specialty societies, signed on to an American College of Emergency
Physicians
<https://www.cmadocs.org/Portals/CMA/files/public/United%20sign-on%20letter%
20ED%20policy%2006.16.2021.pdf> letter expressing grave concerns about the
retroactive denial of coverage for emergency care. While CMA appreciates the
temporary delay in implementing this program, we are urging UnitedHealthcare
to rescind it permanently, and believe there is a better way to ensure that
patients access the right care, in the right place, at the right time.

 

For questions regarding the new program, contact UHC Provider Services at
(877) 842-3210.

 

 

 

 

Brian Potts MD, MBA
Managing Editor, CAL/AAEM News Service

 

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