Medicaid Refusing Payment for Emergency Department Care?

When telling people what I do for a living, work as a nurse practitioner in the emergency department, many respond with some variation of "I don't know how you do what you do".  They assume the ER is filled constantly with blood, guts and gore.  Nope, sorry folks, the emergency department treats mainly non-emergent conditions.  Disappointing, I know.

The other day at work, for example, an adolescent patient checked into the ER to have his basketball participation papers completed.  He needed clearance to play in the next day's game because he was recovering from a rash and would not be allowed to reenter competition without the required medical release form.  He sat for hours in the waiting rooms because his 'complaint' was obviously at the bottom of the triage list, he was deemed non-emergent, level 5.  

The patient's mother became increasingly upset.  To her, basketball forms were certainly an emergency and she made sure to tell me what a big game he would miss if this paperwork was not filled out correctly.  She berated me for his wait time as he was missing precious sleep necessary before the tomorrow's game (maybe she should have taken care of this problem before 9pm?).  It was all I could do to keep from telling her that about 30 minutes earlier we were performing CPR on the patient in the room next door and she was now sitting one thin wall away from a dead body- an actual emergency.

Misuse and abuse of emergency department services is rampant in our country.  Some states are starting to take notice and acting on this costly issue.  Washington State, for example, has declared that it's Medicaid program will no longer pay for medically unnecessary emergency room visits blocking payment for 500 different conditions- no exceptions.  Chief medical officer for Washington State's Medicaid program, Dr. Jeff Thompson, says "The ER cannot be the medical home of the 21st century, we will not pay for diaper rash treated in the emergency room".  Statistics for the state show that some patients visit the emergency room more than 120 times each year costing taxpayers $20,000 to $25,000.  

So, what happens when a patient presents to the emergency department under these new regulations?  The physician and hospital become responsible.  If the patient receives treatment, the hospital and medical provider eat the cost of care.  Dr. Thompson hopes these regulations will encourage providers and hospitals to step up and become better stewards of public resources, deterring non-emergent ER visitors.  It seems simple to deter non-emergent patients, right?

Working in the emergency department I can tell you deterring non-emergent patients from the ER is not so clear cut.  The Emergency Medical Treatment and Labor Act (EMTALA) mandates that every visitor to the ER receive a medical screening exam.  This means that patients must be seen regardless of their complaint or ability to pay.  Even if you present to the emergency room for a paper cut on your pinky finger...by ambulance (it happens all the time) you must be seen based on federal law.  Sure, federal law doesn't demand that you treat non-emergent patients but you still must see the patient and complete medical documentation.

In short, federal law mandates that all patients presenting to the emergency department receive screening by a qualified medical provider.  Meanwhile, many state Medicaid programs won't pay for these visits.  Even though providers are simply complying with federal law by seeing all patients presenting to the ER, states deem this improper use of resources and refuse to pay.  And, you might as well forget collecting payment directly from the patient- Medicaid will not allow it. 

Yes, I agree that misuse of the emergency is a major, costly problem contributing to the inefficiency of our medical system.  Providers are stuck in the middle.  States need better systems for deterring patients from the ER on the front-end, before they show up in the ambulance bay with a stubbed toe or head lice.  

How does your state handle non-emergent emergency department visits?  Does your hospital have a system in place for screening out non-emergent patients?

 

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