Medicaid officials in some states are denying coverage for emergency department visits based on final diagnosis codes rather than the symptoms that brought the patient in, according to the American College of Emergency Physicians (ACEP).
ACEP said cash-strapped Medicaid officials are increasingly implementing plans to deny payment for emergency department services if the patient is ultimately determined to have a non-urgent condition.
For instance, a patient who comes to the hospital complaining of chest pain may be discharged with a diagnosis of heartburn. Medicaid could deny payment to the hospital for treatment of that patient based on the non-urgent diagnosis, even though a physician wouldn't know the chest pain is heartburn and not something more serious, such as heart attack, when he or she first sees the patient, ACEP said in a press release.
"A physician does not know the diagnosis when the patient walks in," said David Seaberg, MD, president of the American College of Emergency Physicians, in a press release. "This applies 20/20 hindsight to possibly life-threatening conditions in violation of the national 'prudent layperson' standard designed to protect patients' health plan coverage of emergency care."
State Medicaid offices are reportedly relying on the Billings algorithm, created by John Billings, JD, of New York University's Wagner School of Public Service, to determine which diagnoses are non-urgent and therefore don't warrant Medicaid reimbursement.
Billings himself said his tool is not intended for use in individual cases as a triage tool or as a mechanism to determine whether emergency department (ED) use is appropriate. Rather, he developed it to determine whether some patients visiting emergency departments could have been treated in a primary care setting.
"It produces a probabilistic estimate for a broad range of diagnoses as to whether patients visiting an emergency room with that diagnosis could have been treated in a primary care setting or the condition was potentially preventable/avoidable with timely and effective ambulatory care," Billings said in the press release.
According to ACEP, the state Medicaid office in Washington state, for instance, has developed a list of more than 500 diagnoses deemed "non-urgent" for Medicaid emergency patients, including urinary tract infection, bronchitis, and sprains, for which the state will not reimburse hospitals.
Jim Stevenson, of the Washington State Health Care Authority, which administers that state's Medicaid program, told MedPage Today that his department was directed by the state legislature to "find a way to stop paying for non-emergency visits to the ED, and we've been working with doctors and hospitals to define that."
The healthcare authority's controversial plan to not pay for more than three emergency department visits for Medicaid patients was overturned in November by a Washington state court on procedural grounds. The authority's current plan to curb emergency room spending calls for implementing the new "medically necessary" payment method on April 1.
In the meantime, the Medicaid office is developing a set of protocols that hopefully will allow the doctor to more easily determine when a patient in the ED has a non-emergency condition, Stevenson said.
Seaberg said he worries that Medicare and private health insurers will follow suit and attempt to deny coverage based on final diagnosis.
"Many non-urgent diagnoses begin with symptoms that could indicate life-threatening emergencies, such as lower back pain that could also indicate a rupturing aortic aneurysm," Seaberg said in the press release. "No patient should ever be in the position of having to diagnose himself."
ACEP advocates for a national "prudent layperson standard" which would require health plans to cover visits to emergency departments based on an average person's belief that he or she may be suffering a medical emergency.