Analysis of a Commercial Insurance Policy to Deny Coverage for Emergency Department Visits With Nonemergent Diagnoses

Key Points Question If commercial insurers retrospectively deny coverage for emergency department (ED) visits based on diagnoses determined to be nonemergent, what visits will be denied coverage? Findings This cross-sectional study found that 1 insurer’s list of nonemergent diagnoses would classify 15.7% of commercially insured adult ED visits for possible coverage denial. However, these visits shared the same presenting symptoms as 87.9% of ED visits, of which 65.1% received emergency-level services. Meaning A retrospective diagnosis-based policy is not associated with accurate identification of unnecessary ED visits and could put many commercially insured patients at risk of coverage denial.