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UnitedHealthcare looks to retroactively deny emergency room claims

UnitedHealthcare is re-examining its policy on emergency department visits, and is now evaluating ED claims to determine if the visits were truly necessary for commercially insured members, the nation’s largest insurer recently revealed in a notice on its website.

Claims that are deemed non-emergent — meaning not a true emergency — will be subject to “no coverage or limited coverage” beginning on July 1, UnitedHealthcare said. To determine whether this is the case, the insurer will evaluate ED claims based on factors including the patient’s presenting problem, the intensity of diagnostic services performed and other criteria.

If an ED event is determined to be non-emergent, there will be the opportunity for attestation, which will be sent electronically to the facility in question. If processed in the required timeframe, the claim will be processed according to the plan’s emergency benefits.

This means the amount paid by UnitedHealthcare may be less for incidents it determines are non-emergent.


The move caused controversy on Twitter this week, with many saying it could inspire hesitancy in patients even for events that are true emergencies, such as heart attacks. That would, in effect, lead to lower reimbursement for some providers, who are still struggling to […]

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