Posted: 3/20/2018

Managed Medicaid plans in Maryland (including Amerigroup, Jai Medical, Priority Partners, UHC MCO, and Maryland Physicians Care) have been denying payment to hospitals for emergency department (ED) treatment of minor medical emergencies. And on March 15, NBC Nightly News reported that Anthem/Blue Cross Blue Shield is doing the same under its new “avoidable emergency room” policy in 6 states: New Hampshire, Missouri, Kentucky, Georgia, Indiana, and Ohio – “ and this could expand.” But if patients are not to go to EDs unless they are having a “true emergency,” NBC anchor, Lester Holt, asked, “How are they to know?”

The Emergency Medical Treatment and Labor Act (EMTALA)

Under EMTALA EDs must provide “medical screening” and stabilization to any individual who presents to the ED for care of a medical emergency.

What is a medical emergency?

According to EMTALA, an emergency medical condition (EMC) is defined as "a condition manifesting itself by acute symptoms of sufficient severity (including severe pain) such that the absence of immediate medical attention could reasonably be expected to result in placing the individual's health [or the health of an unborn child] in serious jeopardy, serious impairment to bodily functions, or serious dysfunction of bodily organs." 

And when is a patient stabilized? 

EMTALA provides a legal answer: The hospital is required to “provide such medical treatment of the condition as may be necessary to assure, within reasonable medical probability, that no material deterioration of the condition is likely to result from or occur during the transfer of the individual from a facility, or, with respect to an emergency medical condition described in paragraph (1)(B) [a pregnant woman who is having contractions], to deliver (including the placenta).”

In real life, a medical emergency is whatever medical condition a “prudent layperson” judges to be serious enough to require a trip to the ED. This can vary from a 3 AM ED visit for a viral upper respiratory infection with a cough that keeps one awake to crushing chest pain due to a massive myocardial infarction. It’s up to the “prudent” patient to decide what constitutes a medical emergency and seek treatment in an ED; it’s not up to the hospital or the physician – and not to a managed care plan, but these plans have implemented computer algorithms that scrub hospital ED claims and reject payment based on the final diagnosis, not the presenting complaint.

If the final diagnosis is not on the “automatic payment list,” the Medicaid plans will pay for a medical screening (revenue code 0451) but not the ED facility fee (revenue code 0452). This amounts to about a $50-90 for the screening  – and for the ED facility fee, they pay nothing. Zip. Zero. Nada. Rien. Bupkis.

What is an ED physician to do?

I can understand why these plans don’t want to pay for unnecessary ED visits. And yes, there is ED abuse by patients who use the ED as a very expensive source of primary care. For minor problems, care can be provided at a doctor’s office, an urgent care center, or even a walk-in clinic at a pharmacy or mall. But what is the ED physician to do when presented with a real patient with a real complaint? The physician must determine the acuity of the patient’s condition and the risk of an adverse outcome and then (only then) treat accordingly. Is it reasonable to expect a physician to do a screening and send the patient to another facility for treatment? I don’t think so.

The fatal headache

Let’s look at a hypothetical patient who presents to the ED with a headache. This pain was severe enough to bring the patient to the ED – “chief complaint: headache”.

Now the physician must of course determine what’s causing the headache before recommending treatment. If it’s due to the stress of a family problem, ED treatment is fairly simple (though the family problem gets addressed in a different setting). But what if the head pain is due to a subarachnoid hemorrhage or expanding tumor? It’s a well-known clinical aphorism that is driven into the head (so to speak) of every medical student that if a patient complains of “the worst headache in my life” the physician must rule out a leaking aneurysm. And if you ask the patient, that may be exactly the reason the patient came to the hospital. “This is the worst headache I’ve ever had, doc.,” they say. (Unsaid: “Why else would I be here?”)

So the ED physician does a neurological exam and orders a CAT scan; the scan is negative and the patient is released with an analgesic – final diagnosis: “tension head ache.”

Now the hospital submits the bill for the use of resources of the ED – the facility fee – and the plan rejects it as a “non-emergency” based on the final diagnosis and it pays for only a screening - even though the entire evaluation was medically necessary in order to have a safe discharge. After all, if the patient did have a leaking aneurysm and hadn’t been properly evaluated it would have been a catastrophe!

The physician gets paid, but not the hospital

What about the physician’s fee? The plan rejects payment to the hospital for the ED facility fee, but it pays the doctor’s professional fee.  So wait a minute: The physician’s emergency service was medically necessary but the ED facility where they did the evaluation wasn’t? How can that be? I’m not proposing that the plan shouldn’t pay the physician (it should), but this is not the way to reduce ED over-utilization; it’s a way to deny payment for medically necessary ED care.

These plans appear to be saying that EDs should perform a medical screening and triage low acuity patients to an urgent care center or to a physician’s office. But what if the hospital doesn’t have an urgent care center? What if it’s 2 AM and the patient is in distress or in pain? I don’t think it’s reasonable to expect hospitals, especially small ones, to incur the huge cost of setting up an urgent care center just for their own low acuity ED patients. It is similarly unrealistic to expect EDs to refer these patients out the door to their own physician’s office. What if they don’t go and something bad happens? What if that nasty headache really is from a leaking aneurysm and the patient dies on the drive across town to his doctor’s office after being “screened” at the ED? Would the hospital be held liable? Probably.

The plans are saying it’s OK for the physician to bill for their professional service with place of service, hospital ED, but for the hospital, the place of service would be “somewhere else” – but not their ED.

And what is a patient to do?

Lester Holt’s rhetorical question has very serious implications. In the case of Medicaid plans, patients are presumed to be indigent and the hospital takes the financial hit. But what about members of a commercial plan? NBC reported on an Anthem family billed for 12 thousand dollars in denied ED claims for a child with serious allergy and asthma problems.

Anthem’s unstated message is, “If you’re not really sick, don’t go to the ER or you’ll have to pay for the visit yourself.”

The door to the ED is always open. EMTALA forbids hospitals from discouraging patients from seeking ED care for financial reasons, but isn't that just what Anthem is doing? Should patients be required to self-diagnose and decide whether that headache or pain in the chest is a "real emergency"? Should they stay home and pop TUMS or Tylenol instead of seeking emergency medical care? I personally don't see how this practice is ethical, and I don't think, as long as hospital EDs are open to all comers, that it should be legal.