Even when MCOs authorized patients to seek emergency care, researchers discovered their claims were still denied or downcoded. Out of the 980 visits made during a 12-month period between 1995 and 1996, 89 percent of these patients belonged to managed-care plans that require preauthorization for emergency care. In a little over half (56 percent) of the visits, preauthorization was granted; in 20 percent, preauthorization was denied.
“We also found it alarming that in 24 percent of the visits, managed care gate-keepers weren’t even available when the emergency department staff called to obtain preauthorization, even through it was required by the plan,” said Charlotte Yeh, MD, of ACEP and co-author of the study.
Researchers also found that after the initial bills for emergency care were sent to the MCOs, it took more than 100 days in 34 percent of the claims for the MCO to provide a reimbursement response, which was usually either a denial for reimbursement or a downcoded reimbursement. When claims were appealed, reimbursement for these emergency department visits was either reinstated or increased.
“This practice of denials, appeals and delayed reimbursement creates undue financial burden and a morass of red tape for patients and already stressed hospital emergency departments,” said Dr. Yeh. “But it’s important to note that these patients, whether they were authorized for care or not, all sought emergency care and were treated.”
Although federal law requires emergency physicians to provide a medical exam and stabilize all patient who visit the emergency department, insurance companies are not required to pay for these exams. However, in some states “prudent layperson” laws have been passed. These laws define an emergency as any situation in which a prudent layperson, possessing an average knowledge of health and medicine, could expect serious impairment to his or her health. They also eliminate prior authorization for seeking emergency care and retrospective denials of insurance coverage for emergency care. The Balanced Budget Act of 1997 applies the "prudent layperson" definition of an emergency to all patients covered by the Medicare+Choice and Medicaid managed care plans.
“While this study predates passage of many state prudent layperson laws, it underscores the importance of such laws,” said Dr. Yeh. “With a national patients’ bill of rights, we could assure access to emergency care is preserved, eliminate barriers to care, and stop retrospective insurance coverage hassles for everyone."
The American College of Emergency Physicians is a national medical specialty organization with nearly 23,000 members. ACEP is committed to improving the quality of emergency care through continuing education, research and public education. Headquartered in Dallas, Texas, ACEP has 53 chapters representing each state, as well as Puerto Rico and the District of Columbia, and a Government Services Chapter representing emergency physicians employed by military branches and other government agencies.
Journal
Annals of Emergency Medicine