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UnitedHealthcare recently announced that it would go ahead with new coverage standards for emergency-level care, which took effect on January 1, and this drew the ire of the American Hospital Association, which is urging the UHC to repeal the policy.

Beginning January 1, UHC began reviewing claims for emergency services to assess whether a patient should access emergency care. If UHC believes emergency-level care is not guaranteed, it may reject the claim.

“The upshot is that patients must then pay for their care without any help from their health fund, or the emergency department and physicians caring for the patient forego the bills and absorb the loss of reimbursement,” the American Heart Association wrote in a letter to the UHC. .

The hospital’s advocacy group said that because universal health coverage announced the change after so many people had already chosen their health plans for the year, patients would likely be caught unaware when coverage was denied for emergency care.

The American Heart Association has expressed a number of concerns – chief among them that the new coverage standards come six months after UHC publicly announced that it will implement the new emergency services coverage policy until at least the end of the public health emergency. With the number of COVID-19 cases on the rise again, the American Heart Association maintains that PHE is far from over.

Another problem is that while the American Heart Association views the new coverage standards as a slight improvement from what UHC sought to implement over the summer, which would have retroactively denied emergency department claims, it has a caveat that any improvements may be undermined.

“Improvements include recognition by UHC of the importance of considering symptoms that a patient believes require emergency care and not just a definitive diagnosis, which can only be determined after an examination by a medical professional and related diagnoses,” the American Heart Association wrote.

But the group said UHC will continue to take into account the final diagnosis and “other relevant information,” which it failed to fully specify. In the absence of this specificity, the new coverage standards could have the same detrimental effect on patients and providers as the original policy, the organization asserts.

What is the effect?

The American Heart Association is concerned about the potential impact this could have on both patients and caregivers.

“Like its predecessor, this new policy will make patients more reluctant to seek needed emergency care for fear of being denied coverage and will add a significant burden to the providers who treat them,” the group wrote.

The American Heart Association also believes that the policy will overburden the clinical workforce in hospitals at a time when the demands on health care workers are already great, pulling doctors away from the bed to collect, review and submit papers.

This would contribute to the risk of administrative burden, “because this policy allows UHC to manipulate its coverage standards through the vague standard of “other relevant information,” according to the group.” Failure to clearly define coverage standards results in patients and providers not knowing, These vague terms will almost certainly cause providers to send huge amounts of paperwork to UHC to meet any information it requests in order to agree to coverage.”

The American Heart Association cited statistics indicating that there are 450,000 fewer health care workers nationwide than in February 2020.

A request for comment by UHC was not immediately answered.

Big trend

In June 2021, Universal Health Coverage rolled back a proposed retroactive policy rejecting emergency department claims.

The policy, which was due to go into effect July 1, means that the UHC will evaluate ED claims to determine if visits are truly necessary for commercially insured members. Claims considered non-emergency will be subject to “no coverage or limited coverage,” according to the insurer.

But this move led to a lot of backlash. The American Heart Association objected to the policy from the start, saying that a retroactive refusal to cover emergency-level care would put patients’ health at risk.

The policy also created a file Excitement on TwitterMany say it may raise reluctance in patients, even for events that are true emergencies, such as heart attacks. It will, in effect, lower reimbursement for some providers, who are still struggling to regain their financial health after delayed and deferred care during the COVID-19 pandemic slashed revenue.

This was the backlash, according to a report from New York times, That prompted universal health coverage to backtrack on policy — for now. The believer said to times That policy will be held until the end of the ongoing COVID-19 pandemic, whenever possible.

This is not the first step for a major insurance company. Anthem instituted a similar policy in 2017, deciding not to cover certain emergency department visits if a rushing incident was deemed not an emergency. Anthem rolled back that policy somewhat the following year after an outpouring of objections from providers, who said patients are at a disadvantage when they have to decide whether their conditions constitute an emergency.

On January 1, 2018, Anthem said it will always pay for emergency visits based on certain conditions. These exceptions include provider referrals, ambulances, services for patients under 15, visits associated with outpatient or inpatient admissions, emergency room visits that occur because the patient is either out of state or an appropriate urgent care clinic more than 15 miles away, and visits between the hour 8 a.m. on Saturday and 8 a.m. on Monday, and any visit where the patient receives surgery, IV fluids, IV medication, MRI or CT scan.

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