Conversion Healthcare Blog

The Emergency Room Showdown—At the Frontline of the Reimbursement Fight

Commercial payers have issued another blow in the fight over Emergency Department (ED) reimbursement, with the most recent statement coming from UnitedHealthcare. Under new policy guidelines, up to ten percent of ED claims could be deemed “non-emergent” and denied. This applies retroactively, although it is unclear how far back into historical claims the payer will go. But UnitedHealthcare isn’t alone. They are just the latest in the commercial payer space to take a hardline stance on ED reimbursement. In 2017, Anthem announced a rollout in Indiana that expanded ED claims review and denials policy. At risk were approximately 300 codes considered non-emergent, which the company claims were developed with the input of board-certified ER physicians.

Provider backlash has been swift and loud. According to a Becker’s Healthcare article, the American Hospital Association issued a letter to UnitedHealthcare stating that the new policy would jeopardize patient care:

“Patients are not medical experts and should not be expected to self-diagnose during what they believe is a medical emergency. Threatening patients with a financial penalty for making the wrong decision could have a chilling effect on seeking emergency care.”

While patients are ultimately financially responsible, it is the provider that bears the brunt of the burden. In addition to the administrative resources needed to appeal denials, the new policies add to the growing challenges associated with rising patient financial responsibility. According to a 2018 report from TransUnion Healthcare, patient financial responsibility is up 11 percent from 2017 levels. A more recent 2020 report from the Kaiser Family Foundation found that deductibles rose 111 percent over ten years, outpacing worker earnings by more than four times.

Fortunately, proactive solutions can identify rising risk patients, drive patients to the best site of care, and help protect provider revenues and resources. By combining advanced analytic, machine-learning enabled technologies with skilled care guidance resources, individuals at risk of an avoidable ED visit can be proactively identified, and the factors driving the risk addressed.

With a focus on behavior change, technology-enabled care guidance can help avoid the costly expense of an avoidable ED visit while improving care management and driving to the optimal care path for the patient. Moreover, this approach helps avoid potential patient deterioration by addressing preventable and treatable conditions earlier through the appropriate use of primary care.

Avoidable ED visits are a significant challenge for the entire healthcare system. The Agency for Healthcare Research and Quality (AHRQ) estimates that between 13 and 27 percent of all ED visits could be managed through physician offices, clinics, and urgent care centers. And the potential savings could add up to as much as $4.4 billion annually. While the move by commercial payers to try and address this issue is understandable, their methods push risk and demands back onto providers and patients, who are already overstretched. Suppose payers were to invest in care guidance to help avoid costly and avoidable ED visits. In that case, they could help enable a proactive approach to health outcomes and cost containment while improving the lives and satisfaction of their members.

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