ER, a shortgage coming?

[ENT Doc]

We all know Urgent Care and ER visits are typically a far cry from urgent matters (saw an advertisement for one recently where they were advertising their online check-in process where a woman was gleefully checking in at home). So it is no wonder the market (insurers) has responded. Never thought I'd say this, but Vox appears to be running an interesting series on ER care and the shenanigans surrounding it:

https://www.vox.com/policy-and-politics/2018/1/29/16906558/anthem-emergency-room-coverage-denials-inappropriate

I agree with charging people higher copay for ER use to deter frivolous use (especially for Medicaid), but it seems absurd to make patients pay the whole bill if the diagnosis doesn't meet a specific criteria. Seems like a real battle between Anthem and the ERs that I can't see sticking. These idiotic insurers are undercutting themselves with these policies, as they make people want to flee into the big, fluffy arms of Uncle Sam. So my question is how widespread is this? Curious if this affects consultants brought in to see the patients as well. If it does stick to any degree or in a modified form I wonder what the effect on ER/UC volumes will be...

[Zaphod]

You cant really do that kind of thing, it would mean eventually people staying home with possible serious issues in fear of being stuck with a large bill. Again, they dont know if its serious or not, so they would defer to not going in. That winds up with very poor outcomes overall, and lets face it the largest abusers arent really 'in the system' and would never pay anyway. It will stick the usual middle class person.

Agree on pushing people towards a governmental solution, which to be honest, is likely better for everyone as these kind of issues will continue to prop up. Of course, better depends on them being implemented well and I wont hold my breath for that.

[Zaphod]

Okay, I read it and its just as bad as you would think. Yes there are definitely over use issues in the ER, but you cannot stick people with the bill for coming to the ED with chest pain, sob, and sxs that mimic appendicitis...those are very appropriate. Insurers and their even worse brethren PBMs need a reckoning. Insured individuals, hospitals and systems shouldnt have to fight fight fight just for payment of reasonable services rendered which is standard.

You cant have people fearful of going to the ed with serious symptoms, and we all know some no big deal conditions can have confusing presentations, the whole reason we exist, you cannot expect pts to do this themselves. Otoh, insurance companies will get away with whatever they can, and currently no one is really paying attention to these kind of issues at large, so companies of all strokes have been boundary pushing.

[LizOB]

You can only judge whether an ED visit was appropriate based on the chief complaint.... because that is all that is known before the evaluation and workup. You can't deny payment for "GERD" when the patient doesn't know ahead of time whether it's an MI.

Of course the ED is over-used but I don't think this is the right way to go about it

[Hatton]

This would be like refusing to pay a claim because a breast biopsy is not cancer.  If everyone knew what was wrong and the final diagnosis lots would be saved.  Fairytale

[AndyJ]

Occasionally I have a patient tell me they were sent to the ER by the insurance company (or more specifically they called their insurance company about their symptoms and the employee told them to go). Has anyone else had this happen? I've probably had it happen like 3 times in my career, most recently last week. Now this Anthem BS isn't happening by me, but if it were I would tell everyone to call the insurance company with their symptoms, and when they undoubtedly tell some folks to go to the ER, they ************************ well better pay. For the record, these patients sent by insurance are never even sick.

[GXA]

Agree retrospective review based on final diagnosis is completely inappropriate!  Managed medicaid organizations in our state have been doing this for many years (?decades).  When deemed inappropriate the physician gets about a $15 screening fee and the hospital gets nothing despite the workup/testing completed.

Anthem has said they will pay for pediatric visits and for patients referred in.  I have made it a habit to document when a patient was sent in by an office/on call physician/nurse...

[q-school]

Is this new in your areas?   This is at least the third time I’ve had it cycle through insurance in my career.   There are no new ideas.  

[VagabondMD]

ENTDoc: ...Curious if this affects consultants brought in to see the patients as well...

Anthem has informed that for advanced imaging that occurs in the ER setting, mainly CT and MRI, if their retrospective ER chart review determines that the exam that is ordered is not indicated, they will not reimburse the facility or the radiologist. This determination will be made days or weeks after the fact.

So far, we have not been stung with this, but it is out there. And there’s no reason to think that they would stop at Radiology.

[RogueDadMD]

It's a load of crap, even though it's not entirely new.

Anthem is not covering all peds patients, I believe just 14 and under (or maybe under 14).

They're basing it mostly off nurses who look at ICD 10 codes, and are already denying legitimate claims that needed real workups.

Deterring unnecessary ED use is a worthy goal, but the way to do that is to make it easier to go to a primary care doc/walk in clinic, not penalize patients and the ERs.  I see plenty of patients where they'll wait for 2 hours in the ER at 2am with their kid for a possible ear infection (fever, irritable kid, not toxic) because getting into see a primary care doc is impossible and they don't have the transportation to get there when they want anyway.  And their work isn't going to just let them leave at 11am to go take their kid to some random appointment.

Insurers and others like to paint these people as abusing the system.  It's not. As with so many things, it is the behavior we are encouraging with the system we have designed.  I'm fairly sure none of the parents I meet enjoy spending 1-4 hours in the middle of the night during the ER busy season to be told they need to suction their kids nose and give tylenol.

I also recommend reading this series of tweets from an EM physician: https://twitter.com/MDaware/status/958038772272246785

A brief but nice takedown on why this is both illegal in addition to being immoral/incorrect.

 

[nachos31]

Ahh our healthcare system never ceases to amaze me in all the absurdities of its slow, inevitable implosion.

A few random thoughts:

I hope Anthem gets nailed with a major lawsuit for the inevitable (okay to use that word twice in two sentences?) negative patient outcome.

I'm with Zaphod on awaiting a reckoning for insurance companies, PBMs, etc. They get away with so much messed up...stuff...but have too powerful a lobby.

Patients won't call their insurance companies, they will call their PCPs/triage lines to get their "blessing" to go to the ED.

Patients will also be asking providers to call their insurance companies and plead their cases for them. How delightful.

One potential alleviating measure is to co-locate urgent cares with EDs with a single triage such that most get funneled to UC which can then let ED takeover if a case turns out to be an MI and not GERD, etc.

[q-school]

It’s one thing if there are enough primary physicians to see patients promptly (in our area). When there are not, and calls cannot be returned in a timely fashion, what are patients supposed to do? It’s not like telling the patients it’s not an emergency solves the health issue that caused them to seek help.

[RogueDadMD]

@Nachos31 — a lot of EDs (both general ones and peds EDs) due have urgent cares or fast track areas where patients are routed after triage if assigned a low acuity. It’s often staffed by NPs/PAs.

[nachos31]

Rogue Dad, in my experience (from a limited number of medpeds residency rotations in EDs), those fast track areas are minimally staffed and generally with midlevels, as you stated, and a lot gets punted up to the ED. Moreover, they are a relative drop in the bucket for the volumes coming through busy EDs and then the overflow of minor issues falls on the EDs.

A more robust UC with its own dedicated space co-located with the ED may serve that purpose better. A family friend did her public health dissertation on something dealing with this--I'll see if I can dig any of that info/data up.

[MPMD]

ACEP is howling like a pack of wolves on this very appropriately. It's a terrible policy.

I am actually for sensible policies to decrease ED volume, we need to stop pretending like we can see everyone who wants to be seen because we don't have capacity to do that. But this ain't it and it almost seems wantonly cruel.

I do wish we could figure out a way to sanction truly abusive uses of the ED, but I have no idea how to do that without a) harming some patients with real dz or b) turning us ER docs into moral arbiters.