NYC Health + Hospitals and UnitedHealthcare are set to enter arbitration regarding $11.5 million in denied inpatient medical claims.

These claims are all related to patients who sought emergency department treatment between July 2014 and December 2017. The patients were covered by UnitedHealthcare’s Medicaid and Medicare programs. Their claims through Medicare and Medicaid for emergency treatment were denied, leading to NYC Health + Hospitals’ arbitration pursuit. None of the denied claims were
for cases of ambulatory care, behavioral health, or other services.

NYC Health + Hospitals believes that the claims were wrongfully denied. Since the claims were all related to emergency treatment and not to other services, a NYC Health + Hospitals spokeswoman said they believe UnitedHealthcare has been making claim decisions by substituting “their medical judgement over that of our doctors and nurses.”

These sorts of actions, in which UnitedHealthcare has been making decisions about whether the claims were “medically necessary,” go against its contract with NYC Health + Hospitals. A
UnitedHealthcare spokesman has stated the company disagrees with NYC Health + Hospitals’ view on the claims, but arbitration will solve the matter. The New York City Law Department will handle the dispute over the summer of 2018.

There are several reasons for health insurance companies to deny incoming claims. A customer may have sought treatment for a noncovered charge or went to an out-of-network provider. Some
procedures, such as MRIs or CTs, often require pre-authorization, which may have not been filed. Errors such as an incorrect birthdate or misbilled company also can cause complications. In
these cases, a claim can be rightfully turned down. In the cases of filing errors, the claim may be resubmitted, but sometimes a time delay can prevent a claim’s acceptance. Some of the claims
UnitedHealthcare has been denying may fall into these categories, but whether the denials were fair will be determined in arbitration.

This is not the first time UnitedHealthcare has gone to court over withheld service payments. The NC Medical Society filed a lawsuit in 2004, claiming UnitedHealthcare was denying claims for
necessary treatments to meet its financial goals. The lawsuit ended with UnitedHealthcare settling for $11.5 million.

The NYC Health + Hospitals dispute comes shortly after UnitedHealthcare’s implementation of a new payment policy on March 1. With the change, the payer will review claims to make sure
the filed evaluation level matches the provided care. If there’s a discrepancy, the claim will be reduced or denied based on the policy contract. The aim is to reduce overall emergency department claims’ costs.

Insurance company Anthem made a similar policy change, aiming to reduce the number of patients with low-risk conditions seeking emergency care. The restricted coverage for emergency department visits was met with opposition, leading to some exceptions being added to Anthem’s policy.

Health care providers have concerns these stricter policy changes will cause patients to hesitate before seeking care they may need. Potential patients may be forced to self-diagnose, which can be dangerous and prevent people from seeking treatment. Many people are incapable determining if an ER visit is necessary without the aid of a medical professional.

The UnitedHealth group, of which UnitedHealthcare is a part, is the largest health care company worldwide. It provided service to roughly 115 million individuals in 2016 — a sizable number to be at risk if they choose to avoid emergency care.

UnitedHealthcare provides Medicare, Medicaid, and retirement plans. It also serves more than 885,000 caregivers and physicians, as well as more than 6,100 health care facilities.

The number of emergency room visits per year has increased, going from 130.4 million in 2013 to 141.4 million in 2014, which is an 8.4 percent increase, according to the Centers for Disease Control and Prevention. Both the price and severity of these visits has increased, as well. However, the percentage of non-urgent visits was at 4.3 percent, meaning most treatments were
necessary.

Retail clinics and urgent care centers provide alternatives to emergency room visits, which could pull away from the number of patients seeking care in an emergency department for non-urgent conditions. Anthem’s policy change was aiming for this shift in care, while UnitedHealthcare’s focus is on ensuring hospitals have proper billing procedures.

NYC Health + Hospitals’ spokesperson Robert de Luna has mentioned the company is concentrating on overturning potentially unfair claim denials, but the arbitration is more about changing its internal policies rather than those at UnitedHealthcare. The hospital system has allowed for denials to go unchallenged in the past and for not getting as much money as it could, as a result.

“Our clinicians provide high-quality care and advance our mission every day,” Dr. Mitchell Katz, system president and CEO, said in a statement. “It’s our responsibility to stand up to them and challenge wrongful denials, as all health systems should.”

The arbitration with UnitedHealthcare is one of the first steps on NYC Health + Hospitals’ part to begin implementing its internal changes. With a new emphasis on reviewing denied claims, there may be more changes and challenges on the hospital system’s part toward other insurance providers and payers.

Emergency services are lucrative for a hospital’s income. For NYC Health + Hospitals, which has been losing profits due to improper coding and billing visits, winning the arbitration could make up for some of that lost revenue.

The purpose of the arbitration is on changing NYC Health + Hospitals’ internal policies, but UnitedHealthcare’s status as the nation’s largest public health care system could influence other companies’ medical claims procedures. More insurance companies may also restrict emergency care procedures, or the arbitration could discourage similar action.

UnitedHealthcare still changed its policy, even when several hospitals sued Anthem after implementing its emergency care and other policy changes. New trends may be forming in medical insurance companies’ procedures, with hospital systems like NYC Health + Hospitals taking stock of how those trends will affect health care.

Sources:
www.modernhealthcare.com/article/20180522/NEWS/180529987
www.healthcaredive.com/news/nyc-health-hospitals-seeks-11m-from-unitedhealthcare-over-denied-claims/524199/
www.fiercehealthcare.com/payer/nyc-health-hospitals-unitedhealthcare-claims-denials-arbitration-emergency
www.uhc.com/
www.beckershospitalreview.com/payer-issues/25-things-to-know-about-unitedhealthcare.html
en.wikipedia.org/wiki/UnitedHealth_Group
www.nerdwallet.com/blog/health/managing-health-insurance/5-reasons-health-insurance-plan-deny-medical-bill/