If you think you like your private health insurance, watch out. Private health insurers control the terms of your coverage. What they cover today can be very different tomorrow. Do not count on anything other than having your policy cancelled if you don’t pay your premiums. Reed Abelson reports for the New York Times on United Healthcare’s move to restrict coverage for emergency room visits.
Yes, it’s true that the federal government defines the minimum benefits private insurers must offer. But, there’s a difference between benefits, such as hospital care and physical therapy, and services covered. Insurers have virtually free rein to decide when services are medically necessary and to delay and deny care, even when your treating physician deems it medically necessary. In theory, insurers must follow generally accepted medical standards. But, their decisions are usually not subject to public scrutiny. So, watch out!
United Healthcare’s move on emergency room visits is just one among hundreds of changes to its coverage policies that received some public attention and some pushback. Imagine all the coverage policy changes that no one is aware of–e.g., increases in copays, narrowing of provider networks, more restrictive medical necessity protocols, and new administrative hurdles. All of these “innovative” insurance designs can jeopardize access to critical care.
Coverage denials for emergency room visits that United Healthcare deems non-urgent received attention mainly because it hurts the doctors and hospitals’ pocketbooks. So the providers’ lobbying arms organized and spoke out against the policy change. Even still, United Healthcare is saying that it’s delaying implementation of its restrictive ER coverage policy, not reversing it. When an insurer’s policy changes affect patients, without reducing revenue for doctors and hospitals, the policy change often does not get the same attention.
As it is, millions of Americans are taking grave health risks in emergency situations. They stay home to avoid responsibility for huge out-of-pocket costs associated with emergency room care. In some cases, staying home can lead to heart attacks and other deadly health conditions.
United has profited handsomely as a result of people using the emergency room less. During 2020, the novel coronavirus pandemic led to a 27 percent drop in the number of emergency room visits. United’s proposed ER coverage policy change would help ensure that its costs for emergency room care do not creep back up, eating into its new-found profits.
Recent data suggests that United’s profits likely came at the cost of the premature loss of life of thousands of its members, who ended up dying of heart disease, diabetes and other illnesses because they went without emergency care. Anthem tried a similar policy change several years ago. Emergency room physicians sued the company on the ground that Anthem was violating consumer protections under federal law.
Here’s more from Just Care:
- Office of Inspector General finds that Medicare Part D plans inappropriately deny drug coverage
- Well-kept secrets of Medicare Advantage plans
- Inappropriate Medicare Advantage care denials appear widespread
- MedPAC: Traditional Medicare consistently costs less than Medicare Advantage
- Four things to know if your income is low and you have Medicare
