New UnitedHealth policy ends some non-emergency coverage

UnitedHealth Group will no longer cover members’ non-emergency services from out-of-network facilities, effective July 1.

The policy change will impact everyone from individuals seeking addiction treatment at day facilities to those who want rehabilitative services after a knee surgery at locations not in-network. Any non-emergent sub-acute inpatient and outpatient services that are out of network will be impacted, which essentially includes “step down” medical and behavioral healthcare at skilled nursing facilities or residential treatment programs.

“UnitedHealthcare has one of the largest care provider networks in the country,” a spokesperson wrote in an email. “We encourage our members to see these providers whenever they can as they have the lowest out-of-pocket costs. We recognize at times our members may need to see out-of-network providers and most of our plans also offer out-of-network benefits in their service areas.”

But for patients whose conditions are not emergencies, those out-of-network benefits have ended. The company rolled out the change to a select number of plans in July and plans to have the policy fully implemented for every member enrolled with out-of-network benefits by mid-2022.

A spokesperson declined to name which plans are immediately affected and how many members the policy change will eventually impact. UnitedHealth Group counted 49.4 million enrollees at the end of its most recent first quarter on March 31.

The Minnetonka, Minn.-based health giant said it sent a letter notifying Optum subscribers of the change in early June. But a report from WRDW-TV/WAGT-TV in Georgia said UnitedHealthcare gave patients a week’s notice that a nearby hospital would no longer be available in-network.

The insurer did not immediately respond to a request over whether coverage with University Health Care Physicians and practices was linked to this policy, and UnitedHealthcare and the Augusta, GA-based system eventually came to an interim agreement that stretches until Nov. 30.

UnitedHealth Group’s policy change comes as the company tightens the reins on where members can get service.

In late June, a group of plastic surgeons hit the company with a proposed class-action, alleging the nation’s largest insurer “routinely and consistently” denied claims for a type of breast augmentation surgery requested by cancer survivors despite a federal law that requires them to cover the procedure.

A November 2020 analysis from Bloomberg Law found at least seven instances of insurers—including UnitedHealthcare—fighting these claims in court, saying these disputes were indicative of payers becoming increasingly aggressive about lowering costs and reducing provider reimbursements. One expert said the litigation signaled that providers were attempting to overcharge insurers. Most of these disputes were resolved through undisclosed settlements, including UnitedHealthcare’s.

Earlier in June, the company also unveiled a policy to retroactively deny emergency department claims. After complaints from the American Hospital Association, American College of Emergency Physicians and other providers, the insurer quietly announced it was pausing the policy through a customer service tweet.

That same month, UnitedHealthcare was also hit with a suit from a laboratory in New Jersey, which alleged the insurer systematically denied paying the claims for 51,000 COVID-19 tests administered to its beneficiaries. Two days later, UnitedHealthcare announced it would increase what it pays pediatricians and family medicine clinicians to match Medicare rates.