United Health Care Proposes Concerning Changes to Payment for Emergency Services and Hospital Clinics

June 9, 2021

United Health Care (UHC) recently announced two policy payment policy changes impacting hospitals. WSHA has grave concerns regarding these policies and is expressing our concerns to staff at the Office of the Insurance Commissioner (OIC).  We encourage hospitals and providers with concerns to also contact OIC.

    • Effective July 1, 2021, UHC will subject emergency department claims on its commercial products to internal review and will deny or reduce payment for claims it does not believe meet emergency criteria. In these cases, hospitals will have opportunity to provide attestation that in their judgement the service met “prudent layperson” criteria.  We are concerned the policy change will create financial exposure for hospitals and patients and may discourage patients from seeking needed emergency care.

After publishing the article, UHC announced it would delay implementation of the policy for the duration of the public health emergency but has not indicated it is willing to withdraw the policy.  We are continuing to monitor this issue.

    • Effective August 1, 2021, UHC plans to implement a policy that will not pay for the professional billing in addition to the institutional portion of hospital clinic services unless a surgical procedure is involved. This would impact hospital-based primary care and specialty care clinics where evaluation and management office visits are the main service performed. We believe the change would have greatest impact on safety net hospitals that operate hospital-based clinics due to high concentrations of Medicare and Medicaid patients and 340B status, and academic medical centers where professional services are provided by a faculty practice organization that is distinct from the hospital.

WSHA will continue to monitor these issues. (Andrew Busz, AndrewB@wsha.org)


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