With ER Visits Rising, Payers Pitch mHealth and Telehealth as an Alternative

With hospital emergency departments moving back toward pre-COVID-19 traffic levels, some payers are renewing efforts to steer their members away from the ER and toward other resources, such as mHealth apps and telehealth services.

UnitedHealthcare recently announced that it will be changing how it reviews ED visits for coverage, with a formula that determines whether the reason for the visit qualifies as an emergency.

“UnitedHealthcare will utilize the Optum Emergency Department Claim (EDC) Analyzer to determine the emergency department E/M level to be reimbursed for certain facility claims,” the insurer explained in a fact sheet. “The EDC Analyzer applies an algorithm that takes three factors into account in order to determine a Calculated Visit Level for the emergency department E/M services rendered.”

The idea behind these reviews is that EDs often treat people for minor issues that could have been treated in another, less intensive and expensive location, including virtual care. With average costs for an ED visit topping $2,000 – 12 times the cost of a visit to the doctor’s office and 40 times the cost of a visit on a direct-to-consumer telehealth platform – insurers are trying to reduce those expenses and teach members to seek out the appropriate care path. UHC says it stands to save $32 billion a year by doing this.

It’s not a new strategy. In 2017, Anthem launched a new ER visit review policy in Georgia, telling members it wouldn’t reimburse for visits that could have been handled through the health plan’s mHealth app, a telehealth visit or a visit to a retail clinic.

“This is not to discourage somebody with an emergency condition who needs to go to an ER to go there,” BCBSGa spokeswoman Debbie Diamond told the Atlanta Journal Constitution when news first broke of the policy change. “Healthcare is becoming more and more expensive. It’s a way to make sure that people are getting quality and affordable care.”

Anthem officials emphasized that its policy wouldn’t be hard and fast, and that officials would review each claim to make sure they covered appropriate ER visits.

Still, the policy was met with backlash. In 2018, the American College of Emergency Physicians (ACEP) and Medical Association of Georgia (MAG) filed a lawsuit against Anthem, saying the policy creates a dangerous situation where members might delay or avoid going to the ED, possibly putting their lives in danger.

"In an emergency, seconds count," MAG President Frank McDonald, MD, MBA, said in a press release. "Even stopping to consider if it's an emergency could mean the difference between life and death. Patients should never hesitate to seek emergency care out of fear of getting a large bill."

The outcry caused payers to take a step back from developing new ER policies, though Aetna was fined $500,000 last year by California’s Department of Managed Care for denying certain ER claims. Those policies were also put on hold during the pandemic, which saw providers and payers emphasize connected health as an alternative to in-person care.

With the pandemic easing, payers are once again moving to reduce unnecessary and costly ER visits, either through value-based care plans that emphasize care management to reduce the chances of a serious health issue or alternative channels of care, like telehealth and mHealth.