Addressing UHCs stance on non-emergent ED visits
UHC announced that they will be assessing emergency department claims to determine if the ED visit was emergent or non-emergent effective, now after the PHE waiver (likely 2022). This may seem like deja vu because UHC attempted a similar approach in 2018 regarding claim submission reviews.
Addressing UHCs stance on non-emergent ED visits
Tiffany Ferguson, LMSW, CMAC, ACM
Right time, right place, right setting…. well maybe. In UHC’s network bulletin ….that was quickly retracted for delay after the AHA and AMA expressed extreme ethical concerns.
UHC announced that they will be assessing emergency department claims to determine if the ED visit was emergent or non-emergent effective, now after the PHE waiver (likely 2022). This may seem like deja vu because UHC attempted a similar approach in 2018 regarding claim submission reviews.
Factors provided included that the evidence of emergency must meet the patient’s presenting problem, intensity of diagnostic services performed, and other complicating factors or external causes. Claims determined non-emergent will be subject to no coverage or limited coverage.
If the hospital event is determined non-emergent, UHC will be submitting a notification of denial either electronically or by mail with the option for submission to appeal via attestation. Ability to argue the claim will be considered on the “prudent layperson standard.”
So, what does this mean and is it possible that other payors will soon follow a similar process. Our team has helped many organizations in the past realize that just because you accept that patient in the ED and treat them, it does not mean your claim is paid if the service could have been completed in a primary care office. With the movement to triple aim and although this policy hurts our quadruple aim, provider engagement, hospitals must utilize their existing network to open access to care for patients that do not belong in the ED and could easily be managed in urgent ortho, urgent care, or same day/ walk-in primary care settings. Let us not forget the expansion of telehealth and the many options our patient populations can now do from their phone via app to access healthcare services.
So how does this interact with EMTALA?
EMTALA only requires that any individual who comes into the ED and requests medical treatment must receive a medical screening examination (MSE) to determine whether an emergency medical condition exists. The level of the medical professional that provides the MSE is determined by the hospital and medical staff bylaws. The law does not require the MSE be performed by an ED physician.
If an emergency medical condition exists, then the patient must be treated until stabilized, issue resolved, or transferred to the next appropriate level of care regardless of ability to pay. Now, what if an emergency medical condition does not exist? If the required MSE occurs, the patient can be offered a lower cost option of care and does not have to continue services in the ED.
For those living in the value-based world, health systems track and attempt to intervene in the costs of unnecessary ED visits. However, many hospitals and physicians are still living in the door to doc time of getting patients through the system, misinterpreting volume as value for their emergency departments. Having a front-end and gatekeeper strategy is once again evident to avoid the back-end rework and potential for further denials beholden to payor claims for denials and appeals by attestations within a limited timeframe.
Recommendations to stay prepared include:
Relook at your bylaws and consider what provider level really needs to provide the MSE.
Provide marketing in your ED and options for alternatives for your community to access primary care and urgent care services in the evening and weekends.
Provide education regarding what the ED should be used for and where other areas of care can be provided.
Utilize data and review the type of Level IV and Level Vs- Less Urgent and Non-urgent services are being utilized and develop proactive strategies to address these community concerns.
Utilize the ED social worker not only behind the ED entrance but in the lobby to help address patients that arrive with social factors that need community support, resources, and support coordinating more appropriate services.
UHC’s stance is not a new policy, Anthem and the Blues adopted similar practices with much scrutiny, regardless of push backs and delays payers have been downgrading or denying low level and non-emergent ED visits in efforts to curb costs. UHC has chosen to take a more public stance, which led to a public criticism, however you can expect some version of this policy will present itself again by the end of the year or early next year.
Health systems have two options, they can roll up their sleeves and prepare for a fight on the back end or they can consider how the front-end could be improved to avoid the fight until it is necessary.