Medical Justice provides free consultations to doctors facing medico-legal obstacles. We have solutions for doctor-patient conflicts, unwarranted demands for refunds, online defamation (patient review mischief), meritless litigation, and a gazillion other issues. We also provide counsel specific to COVID-19. If you are navigating a medico-legal obstacle, visit our booking page to schedule a free consultation – or use the tool shared below.

Yes, there is a tiny subset of the population that heads to the Emergency Department (ED) at 2AM because they have not had a bowel movement in 5 days.

News flash.

This behavior does not reflect what most people do. Most people actually do NOT want to go to the ED at all.

Most automated messages on physician answering services state the following:

“If you are having an emergency, hang up now, and dial 911.”

So, it was particularly galling to read that United HealthCare, the largest private health insurer in the country, is going to play Monday morning quarterback and deny some claims for what they deem to be non-emergencies in the emergency department.

In the future, if one of UHC’s 70 million members submits a claim for an emergency department visit, UHC will carefully review what health problems led to the visit, the “intensity of diagnostic services performed” at the emergency department (ED), and some context for the visit, like the member’s underlying health conditions and outside circumstances. If UHC decides the medical situation didn’t constitute an emergency, it will provide “no coverage or limited coverage,” depending on the member’s specific insurance plan.

Due to massive blowback from this ill-advised policy, United HealthCare is delaying the policy’s rollout.

But, make no mistake. Winter is coming. And this comes on the heels of a year when EDs were underused for almost everything other than COVID-19.

United is asking its insureds to self-triage and get it right. Or the patient will receive an unexpected bill.

In a 2018 analysis published in JAMA Open Network, researchers found that up to 90 percent of the symptoms that prompted an adult to go to the emergency room overlapped with symptoms of nonurgent conditions, which may be denied coverage in the future. But those same symptoms could also be linked to life-threatening conditions.

Patients will now need to better identify whether their substernal chest discomfort is esophageal reflux or a myocardial infarct. Whether their red eye is run of the mill “pink eye” or a bacterial infection. Whether their headache is atypical migraine or subarachnoid hemorrhage. And on and on.

I suppose patients can use Google before heading to the hospital.

We’ve seen this playbook before.

In 2018, after Anthem announced its similar policy to its members and began denying claims, it received similar backlash and challenges. Anthem ended up effectively rolling back the policy the same year and reversed decisions when members challenged claim denials.

Let’s hope United HealthCare comes to its senses.

We’ll likely spot unicorns and Sasquatch before that happens.

What’s next?

Denial of payment if an insured fails to get prompt emergency treatment for an urgent condition? Because, as everyone knows, the problem wouldn’t have been as severe if the insured had gone to the ED pronto.

Oy.

What do you think? Let us know your thoughts in the comments below.

Medical Justice provides free consultations to doctors facing medico-legal obstacles. We have solutions for doctor-patient conflicts, unwarranted demands for refunds, online defamation (patient review mischief), meritless litigation, and a gazillion other issues. We also provide counsel specific to COVID-19. If you are navigating a medico-legal obstacle, visit our booking page to schedule a free consultation – or use the tool shared below.

Learn how Medical Justice can protect you from medico-legal mayhem… 

Jeffrey Segal, MD, JD

Chief Executive Officer and Founder

Dr. Jeffrey Segal, Chief Executive Officer and Founder of Medical Justice, is a board-certified neurosurgeon. Dr. Segal is a Fellow of the American College of Surgeons; the American College of Legal Medicine; and the American Association of Neurological Surgeons. He is also a member of the North American Spine Society. In the process of conceiving, funding, developing, and growing Medical Justice, Dr. Segal has established himself as one of the country’s leading authorities on medical malpractice issues, counterclaims, and internet-based assaults on reputation.

Dr. Segal was a practicing neurosurgeon for approximately ten years, during which time he also played an active role as a participant on various state-sanctioned medical review panels designed to decrease the incidence of meritless medical malpractice cases.

Dr. Segal holds a M.D. from Baylor College of Medicine, where he also completed a neurosurgical residency. Dr. Segal served as a Spinal Surgery Fellow at The University of South Florida Medical School. He is a member of Phi Beta Kappa as well as the AOA Medical Honor Society. Dr. Segal received his B.A. from the University of Texas and graduated with a J.D. from Concord Law School with highest honors.

In 2000, he co-founded and served as CEO of DarPharma, Inc, a biotechnology company in Chapel Hill, NC, focused on the discovery and development of first-of-class pharmaceuticals for neuropsychiatric disorders.

Dr. Segal is also a partner at Byrd Adatto, a national business and health care law firm. Byrd Adatto was selected as a Best Law Firm in the 2021 edition of the “Best Law Firms” list by U.S. News – Best Lawyers. With over 50 combined years of experience in serving doctors, dentists, and other providers, Byrd Adatto has a national pedigree to address most legal issues that arise in the business and practice of medicine.