# Health insurer plans to deny ER claims if it doesn't think you had emergency



## ffemt8978 (Jun 10, 2021)

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						06/2021: How we’re assessing emergency department facility commercial claims
					

Based on feedback from our provider partners and medical societies, we have decided to delay the implementation of our emergency department program until at least the end of the national public health emergency period.  We will use this time to continue to educate consumers, customers and...




					www.uhcprovider.com
				












						Biggest health insurer plans to deny ER bills if it doubts you had an emergency
					

UnitedHealthcare delayed the policy's rollout, but experts worry about chilling effect.




					arstechnica.com
				




For now they've delayed the implementation, but this could be a challenge for EMS.  Could be a lot harder to convince patients to go to the hospital.


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## EpiEMS (Jun 10, 2021)

Policy seems problematic on a heck of a lot of levels. Curious what metrics they proposed to use.


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## Summit (Jun 10, 2021)

Insurance companies are jackholes. Surprise.

THE FUTURE:

Dispatcher: "911, please state your insurance company so we can transfer you to them and they can determine if you are having an emergency in accordance with your policy..."
Caller: "This guy, he dead... send the ambliance!"

Letter from UHC 3 months later:
"Dear Mr. Sucker,

Your claim with Whereverville EMS has been DENIED due to lack of prior authorization for the treatment:
CPR - Unsuccessful

For the diagnosis of:
Cardiac Arrest

We encourage you to contact United Healthcare in advance in the future so that we can authorize appropriate treatment ahead of time and guide you to right care agency.

Get Well Soon,
-Your Caring Insurance Provider

PS Thanks for your premium payment though."


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## E tank (Jun 10, 2021)

There are ER's that prey on the ignorance of the general public....not the ones that are routinely overwhelmed by penetrating trauma and an abysmally ill population (that don't have insurance anyway and so are not part of this discussion) but the ones that see a very good payor mix and throw the diagnostic 'kitchen' sink at every and any complaint that rolls through the door....about time insurance companies start drawing the line somewhere. It is truly becoming absurd in some areas...especially more affluent ones....


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## akflightmedic (Jun 10, 2021)

Ahhhh, but only if there were some plan, some concept, some idea for those who do not have insurance, a plan where they have access to routine medical care, or even urgent care. A plan which does not require them to utilize the ER as their PCP. 

Maybe one of these nations has an idea or two. 





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						Countries with Universal Healthcare 2022
					





					worldpopulationreview.com


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## ffemt8978 (Jun 10, 2021)

akflightmedic said:


> Ahhhh, but only if there were some plan, some concept, some idea for those who do not have insurance, a plan where they have access to routine medical care, or even urgent care. A plan which does not require them to utilize the ER as their PCP.
> 
> Maybe one of these nations has an idea or two.
> 
> ...


Was wondering how many replies it would take for that to come up.


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## akflightmedic (Jun 10, 2021)

I was busy....would have been first but had not logged in for a couple days.


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## PotatoMedic (Jun 10, 2021)

To be fair, by function we have universal healthcare... A very unfuctional version, but one none the less.  For the most part I call 911 and I go to the er and I'll be transported and treated and technically I don't have to give them any billing information.


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## EpiEMS (Jun 10, 2021)

akflightmedic said:


> Ahhhh, but only if there were some plan, some concept, some idea for those who do not have insurance, a plan where they have access to routine medical care, or even urgent care. A plan which does not require them to utilize the ER as their PCP.
> 
> Maybe one of these nations has an idea or two.
> 
> ...



The best evidence on this is that - in the US - insurance doesn’t decrease ED use, it actually increases it. (The Oregon Medicaid experiment is the closest thing there is to a recent RCT on insurance in the US.)

See: https://science.sciencemag.org/content/343/6168/263.abstract


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## akflightmedic (Jun 10, 2021)

Cannot access the article. Yes, I did the "register for free" and then it said site down. Tried a second time, and it went to locked page.

If you have the article in its entirety and can share it, please do so. I am not going to buy it. 

The headline is interesting, but without all the other data points and breakdown by category, I cannot debate or comment.


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## akflightmedic (Jun 10, 2021)

EpiEMS said:


> The best evidence on this is that - in the US in 2008, in Portland, Oregon,- insurance doesn’t decrease ED use, it actually increases it. (The Oregon Medicaid experiment is the closest thing there is to a recent RCT on insurance in the US.)
> 
> See: https://science.sciencemag.org/content/343/6168/263.abstract


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## FiremanMike (Jun 11, 2021)

You guys should see some of the things that insurance is already calling “courtesy transport” and then not paying..  I’ve seen several with an altered level of consciousness and a few with cardiac symptoms..


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## Fezman92 (Jun 11, 2021)

PotatoMedic said:


> To be fair, by function we have universal healthcare... A very unfuctional version, but one none the less.  For the most part I call 911 and I go to the er and I'll be transported and treated and technically I don't have to give them any billing information.


Yeah that’s not universal healthcare.


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## Summit (Jun 11, 2021)

Maybe this is about the scam health systems are pulling where they can bill Urgent Care as an ER visit if it is affiliated with and close enough to a hospital in the same health system. So patients think they are going to urgent care, but surprise! ER bill! (If you are wondering why a million urgent cares have gone up, it is because this is technically legal and health systems are trying to catch as many of these patientS to bill as ER vi$it$ as po$$ible.









						Four mistakes to avoid when going to an urgent care clinic | Alight
					

Urgent care centers have become a common way for people to receive care. Learn some common mistakes to make affordable choices when using this convenient option.




					alight.com


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## PotatoMedic (Jun 11, 2021)

Fezman92 said:


> Yeah that’s not universal healthcare.


Why not?  Anyone and everyone can access it.  Is it ideal absolutely not.  It's the most ineffective and expensive form.


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## FiremanMike (Jun 11, 2021)

PotatoMedic said:


> Why not?  Anyone and everyone can access it.  Is it ideal absolutely not.  It's the most ineffective and expensive form.


Because in a system of universal healthcare, you don't get a bill downstream.


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## Carlos Danger (Jun 11, 2021)

I'm not sure why anyone would think insurers should be forced to pay for EMERGENCY department visits that clearly were not emergent?

Do ED's in countries with universal healthcare use any form of rationing to discourage or prohibit unnecessary ED usage?


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## MonkeyArrow (Jun 11, 2021)

Carlos Danger said:


> I'm not sure why anyone would think insurers should be forced to pay for EMERGENCY department visits that clearly were not emergent?
> 
> Do ED's in countries with universal healthcare use any form of rationing to discourage or prohibit unnecessary ED usage?


Outside of a few very obvious examples, how can you reasonably expect the layperson to know if something is emergent without medical training?

That foot pain could be osteomyelitis. The back pain could be a dissection. The sore throat could be a PTA. It's easy to d/c someone home with pharyngitis after three years of residency training you to exclude more sinister alternatives, but Joe Blow at home doesn't have that.


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## Carlos Danger (Jun 11, 2021)

MonkeyArrow said:


> Outside of a few very obvious examples, how can you reasonably expect the layperson to know if something is emergent without medical training?
> 
> That foot pain could be osteomyelitis. The back pain could be a dissection. The sore throat could be a PTA. It's easy to d/c someone home with pharyngitis after three years of residency training you to exclude more sinister alternatives, but Joe Blow at home doesn't have that.


Because those "few obvious examples" aren't so few. 

We all know that life-threatening emergencies are a small percentage of ED visits. We also all agree, I'm sure, that a W-I-D-E leeway for uncertainty or "over self-triage" is quite appropriate. But we also know that even taking that into account, there are a LOT of people who inappropriately use the ED out of sheer convenience. That raises costs for everyone and potentially takes valuable resources from those with more pressing needs for them, and there is nothing wrong with attempts to dis-incentivize that behavior.


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## johnrsemt (Jun 11, 2021)

Yea lets all push for Universal Health Care it is so much better than what we have now.

I watched a good You Tube video a few months ago, and if I can find it tomorrow I will post it, But I am at work and can't get onto You Tube.  
     A 20+ year old was in Canada skateboarding on a Sunday, fell and broke his forearm (his words):  obvious fx from the multiple video shots.  
He and his brother went to the local ED, waited in the waiting room for 9 hours to be seen,  ED doctor told him it was probably broken, but since it wasn't an emergency they had to leave and go to an Urgent Care type clinic (why they weren't told that when they checked in I have no Idea).  
    They left went to the Urgent Care Clinic, at 1900 on Sunday Evening:  They are closed on Sunday's.
Went back Monday.  2nd person in to the clinic.  took them 2 hours to do the paperwork, got an X-ray and surprise Radial/Ulna Fracture.  Got a Sling and told to go to his family doctor to get a referral to an Orthopedic Surgeon 'if the family doctor thought he needed one'.
   It took until Wednesday afternoon to find a 'Family Doctor' That would take him (20 year old's with no medical history do not need family doctors in Canada was the general answer on the phones calls).   They went to the Family doctor on Friday who said 'Yes you need an Ortho Consult"  I can get you scheduled with one in 3-5 weeks:  Or 'you can drive 5 hours south over the border into the US, go to the closest Emergency room and get this set in a few hours'.

Interesting thing to think of Mexico has Universal Health Care, but you don't see Illegal Mexicans going back home for free health care.


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## Fezman92 (Jun 11, 2021)

Do you think that we shouldn’t have universal healthcare?


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## EpiEMS (Jun 12, 2021)

akflightmedic said:


> Cannot access the article. Yes, I did the "register for free" and then it said site down. Tried a second time, and it went to locked page.
> 
> If you have the article in its entirety and can share it, please do so. I am not going to buy it.
> 
> The headline is interesting, but without all the other data points and breakdown by category, I cannot debate or comment.



Authors’ manuscript is free here: https://www.ncbi.nlm.nih.gov/pmc/articles/PMC3955206/#!po=0.943396

The long and short of it is that there are only two true insurance RCTs done in the US. The Oregon Medicaid one and the RAND health insurance experiment - both are gold standard but the RAND one (which had similar findings) is much older. One reference here: https://www.rand.org/content/dam/rand/pubs/reports/2006/R3469.pdf


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## EpiEMS (Jun 12, 2021)

Fezman92 said:


> Do you think that we shouldn’t have universal healthcare?



As a stand-alone term, universal healthcare is basically meaningless. What is health care (e.g., do you include dental? Prescriptions?)? Are there copays?

There are so many variants on the theme - the NHS, Canada’s provincial Medicare, our Medicaid, etc. all of which are hugely different. 

I do not believe that universal zero fee at point of service care makes sense. I am in favor of at most a catastrophic coverage mandate and subsidies for catastrophic conditions, public health measures, and basic research.


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## Fezman92 (Jun 12, 2021)

What do you define as catastrophic conditions?


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## FiremanMike (Jun 12, 2021)

Fezman92 said:


> Do you think that we shouldn’t have universal healthcare?


I have a VA clinic in my running district and we are there daily to transport people out.

I think universal healthcare is theoretically a fantastic idea.  With that said, you can view what universal healthcare looks like in America by viewing our VA system…it ain’t pretty..


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## DrParasite (Jun 12, 2021)

I think this sums up what is going on.... 

__ https://twitter.com/i/web/status/1403067804417359876


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## EpiEMS (Jun 12, 2021)

Fezman92 said:


> What do you define as catastrophic conditions?



Catastrophic coverage is probably best defined by the financial and/or employment burden - the proverbial “hit by a bus” or a cancer diagnosis, something like a $5,000 deductible. Obviously that is a handwave-y estimate but roughly in line with what you see out in the marketplace.


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## E tank (Jun 12, 2021)

EpiEMS said:


> Catastrophic coverage is probably best defined by the financial and/or employment burden - the proverbial “hit by a bus” or a cancer diagnosis, something like a $5,000 deductible. Obviously that is a handwave-y estimate but roughly in line with what you see out in the marketplace.


I have one. It works in combination with an health savings account. You contribute pre-tax dollars and the earnings are not taxed as long as it's used for qualifying medical expenses which are pretty broad. Balances roll over year to year and when you're 65 you can use it for non-medical expenses and not be penalized. Getting into one in your 20's or 30's generally assures you 10's of 1000's of dollars cash for when you begin to access substantial medical care. They keep premiums low and even if you're deductible is 7500 to 10000, you don't feel a thing. Great way to go especially if you're young...'cause you won't always be and when kids come along and have problems with tonsils, ear infections and broken bones, you'll be covered then too. And because you have cash in hand (it accumulates surprisingly quickly) you can come to terms with providers for a discount.


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## Fezman92 (Jun 12, 2021)

FiremanMike said:


> I have a VA clinic in my running district and we are there daily to transport people out.
> 
> I think universal healthcare is theoretically a fantastic idea.  With that said, you can view what universal healthcare looks like in America by viewing our VA system…it ain’t pretty..


that’s not quite universal healthcare since it’s contained to one company so to speak. Universal healthcare wouldn’t replace hospitals or anything like that, just replacing the private insurance with publicly funded insurance.


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## FiremanMike (Jun 12, 2021)

Fezman92 said:


> that’s not quite universal healthcare since it’s contained to one company so to speak. Universal healthcare wouldn’t replace hospitals or anything like that, just replacing the private insurance with publicly funded insurance.


For that cohort of patients (veterans), it is universal healthcare.  They have publicly funded insurance and a variety of hospitals, clinics, and practitioners that provide all levels of care based on the individual needs of the patient.  It is the US example of what we hear of universal healthcare in other countries, such as “this isn’t an emergency, we will refer you to the next available ortho surgeon” and then you wait for a call.


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## EpiEMS (Jun 12, 2021)

Fezman92 said:


> that’s not quite universal healthcare since it’s contained to one company so to speak. Universal healthcare wouldn’t replace hospitals or anything like that, just replacing the private insurance with publicly funded insurance.


Not necessarily true. Universal "healthcare" takes many different forms in many different countries.

Medicaid is an example of single-payer, which is a form of universal health care (in this case, for a large subset of the population) - Medicaid pays private or not for profit providers for providing care to the population at designated rates.

The NHS, in the UK, is another example of universal healthcare, a classic Beveridge model in which care is provided by public (yes, government employed & owned) providers and facilities at zero cost to patients at point of service.

The Germans have a universal system too, but it's multi-payer - you must either be part of a "sickness fund" (basically, an insurance plan) and these funds pay providers based on contractual arrangements. In theory, this isn't so crazily different from the US, except for the scope of coverage, the mandatory nature of coverage, and that the sickness funds are all not-for-profits. (There is also about ~10% coverage of what we understand as private insurance, which you can get only if you are above a certain income level.)

Singapore has a universal system too, everybody has to have (public) catastrophic coverage & mandatory tax exempt HSA-style accounts (plus a Medicaid-style plan for the poor).

However -- universality is subjective because no system covers all types of care. The NHS, for example, excludes dental & vision care. Medicaid may or may not cover dental (depending on the state).

Point is, universal healthcare is not one concept & may vastly differ across the globe, or even within a country! (The VA vs. Medicare vs. Medicaid, etc.) You can have universal healthcare with public providers, with private providers, or with a combination. You can have universal coverage with or without public insurance options. You can even have universal healthcare without insurance -- think the Soviet Union's model.


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