Changing Insurance Rules for Emergency Rooms

Monday Author:  Susanne Skinner

Emergency Room Entrance, healthcare, health insurance, UnitedHealthcare, regulationsIf we’ve learned anything during our pandemic isolation it’s self-care. We embraced healthy eating and exercise and read up on nutrition. As we jump back into our social routines many of us remain committed to the healthy changes we made.

As I age, health and wellness continue to be top priorities. I have no genetic pre-disposition to illnesses, but the cost of remaining healthy and the financial impact of a major illness can’t be ignored.

UnitedHealthcare’s Policy Change

Thirty million Americans have employee-sponsored health plans and another 56 million (17 % of the US population) are covered by Medicare, a federally run healthcare program  for those 65 or older,

The need for emergency room services is likely to be in our collective futures, even with proactive precautions. A recent article about United Healthcare cracking down on emergency room visits caught my attention. The likelihood of this new policy applying to us is very real.

Beginning July 1st, the new UnitedHealthcare plan will deny the treatment for an emergency room visit if it determines it is not a true emergency. Claims that are determined not to be tied to emergencies will be subject to no coverage or limited coverage based on the patient’s insurance plan.

This proposal calls the question of what constitutes an emergency, and therein lies the argument. Who has the final say? May primary health care providers send patients to the ER because they are not equipped to treat them. There is also the intermediary option of Urgent Care medicine. A likely response there is to “see your regular doctor or go to the ER if the condition persists.”

UnitedHealthcare claims this new ruling is designed to prevent people with non-emergency medical needs from clogging the system. Unfortunately, it invites seriously sick people to second-guess their symptoms for fear of being rejected after the cost is incurred.

What Constitutes an Emergency?

There is no definitive list – but most emergency room physicians agree on these symptoms to help a layperson determine that urgent and/or unscheduled care is required. It is also important to note that unnecessary use of the emergency room is a reality and it costs nearly $32 billion annually. This is a major factor in driving up the cost of health care.

Medical Claim Denied, UnitedHealthcare, health insurance, emergency roomIf you’re not experiencing an emergency, and you don’t have medical insurance or the ability to pay, the hospital emergency room is not legally required to treat you. Some health insurers deny emergency room claims if the person could have been treated by a doctor or an urgent care center. But what if the doctor referred you??

Federal law makes one exception through the 1986 Emergency Medical Treatment and Active Labor Act. This requires certain hospitals to treat acutely ill patients, whether or not they have medical insurance.

Who is Affected?

The proposed new restrictions do not apply to patients with Medicare Advantage or contracted Medicaid coverage with UnitedHealthcare. For now. But we all know how this works.

A case in point is American Airlines—the first legacy carrier to charge a fee for a checked bag. It wasn’t long before the other airlines fell in line behind them. The airlines claimed the fees were to help offset the high cost of jet fuel.

In 2008 the fee was $15 per bag each way. Today the one-way fee is $30 for your first checked bag, $40 for the second, $150 for the third and $200 for the fourth.  See where I’m going with this?  The competitive nature of the industry means all major insurance carriers will follow suite.

The fallout from this proposed change deserves a closer look. As many as 1 in 10 claims could be rejected, and that means you and I and our health care providers need to understand the new rules of the game.

The Rising Cost of Health Care

Healthcare costs, medical insurance, health insurance, medical claimsAs we age, we will need more money for healthcare. This is not a hypothetical statement. By the time you reach 65, average healthcare costs are $11.3K per person, per year in the United States. This is nearly triple the annual cost paid in your twenties and thirties.

Financial hardship has impacted many older Americans. Senior citizens declaring bankruptcy has more than doubled since 1999, and the leading cause is high healthcare costs coupled with increased in health risks and lower incomes.

Under the new policy, which was to go into effect next month, UnitedHealthcare planned to analyze the medical records of its customers’ visits to emergency rooms to establish a pattern and determine if it should cover those bills. Major hospitals and medical groups are demanding that United halt the policy.

Health Care and the Elderly

In 2017 Medicare Part B and Part D premiums and out-of-pocket costs took 25% of the average social security benefit. That number is expected to increase to 50% by 2030.

healthcare insurance, checklist, emergency room, medical insuranceBut the big unknown remains healthcare expenses. As we age, annual healthcare increases and despite insurance there are co-pays, deductibles, and services or prescriptions that aren’t covered.  Fun fact—the term elderly means 65 or older.

Americans now spend twice as much on health care as they did in the 1980s. But the main driver of the increase is not drug costs or medical services. In fact, the costs related to medical services have decreased by about a third since the 1980s. The biggest reason for the increase is insurance costs, which have grown by 740% since 1984,

Beyond the many uncertainties around this proposed mandate, it is guaranteed to invoke the law of unintended consequences if people delay treatment for serious illnesses. Individual state regulations also affect the way you’re treated and your health insurance company’s decision to pay for that treatment.

The American Hospital Association is calling for a full and permanent reversal. In the face of growing opposition from hospitals and doctors, United Healthcare said it would delay the plan until the pandemic has ended.