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With the pandemic in the rear-view mirror, people are going back to the ER, and payers are trying to steer them instead toward mHealth apps, telehealth platforms and retail clinics.

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.

 

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