The AAMC joined other health care stakeholder groups in a June 16 letter to United Healthcare (UHC), urging the insurer to rescind its proposed policy to retroactively deny coverage for emergency care. The letter was signed by more than 30 physician, hospital and patient groups including America’s Essential Hospitals, the American Medical Association, and Federation of American Hospitals.
UHC announced a new policy in early June that would allow for emergency department claims to be retroactively denied if the insurer deemed that the situation was non-emergent. After significant concerns were raised about the new policy, UHC delayed the proposed policy until at the least the end of the public health emergency.
The stakeholder letter to UHC raised significant concerns with this policy, particularly as it relates to the potential for patients to avoid seeking care in an emergency situation because they are concerned about being billed after the fact. “Patients do not have the full set of knowledge and tools to assess the level of care they may need,” the letter states.
Additionally, the letter notes that the policy may be in violation of federal patient protection laws, including the “prudent layperson (PLP)” standard. This legal protection ensures that patients are able to seek care in an emergency department by requiring payors to cover any medical condition “manifesting itself by acute symptoms of sufficient severity (including severe pain) such that a prudent layperson, who possesses an average knowledge of health and medicine, could reasonably expect the absence of immediate medical attention to result in: 1) placing the health of the individual (or a pregnant woman or her unborn child) in serious jeopardy; 2) serious impairment to bodily functions, or 3) serious dysfunction of any bodily organ or part.” PLP protections also dictate that payors cannot deny provider reimbursement based on a patient’s final diagnosis.
“Only full and permanent rescission of the policy will ensure the safety of our patients and your enrollees, and we urge you to take such action immediately,” the letter concluded.