Upfront payment for non emergent conditions

Specialties Emergency

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So just curious to hear some other opinions of this. Our hospital is considering a serious overhaul of its ER practices due to the upcoming reductions in Medicaid. All patients presenting with any complaint are to have a medical screening exam (as per EMTALA) performed by the mid-level provider stationed out in the triage area. If, according to the medical screening, the person does not have an emergent condition, an appointed person (new "care finder" position) will give the person a choice of either being seen in the ER but they will have to pay upfront for the care OR they will be provided with the names of clinics where they can go to be treated. According to EMTALA, the ER is not required to treat anyone other than those presenting with emergent conditions or in active labor. I work in an inner city not for profit hospital where it seems the majority of the patients are uninsured or on Medicaid. It is also a rather poor area and of course people frequently use the ER for routine medical problems. I was just wondering what anyone else thought of this idea.

Specializes in PCU.

I personally think the OP's hospital policy might actually work, if they are diligent in weeding out the FFs and hang nails that come through the ER door.

As to this new protocol leading to missed diagnoses...please! Even regular ERs that take everything make incorrect diagnoses and send people home at times. Has nothing to do with can you pay or not. In '97 I went to the ER per my PCP request, only to be told I "had an infection", given PO abt, and sent home. I was later taken back to ER emergent w/burst appy and peritonitis...now have a zipper-like scar from missed hot appy.

Weeding out those people that abuse the ER will make it more cost effective to run ERs and will allow the staff to concentrate on the truly emergent people.

Specializes in Critical Care, ED, Cath lab, CTPAC,Trauma.

.I still see this traveling down a path of lawsuits and poor care. I agree that the "I'm here for a pregnancy test" crap can then be triage else where....extreme caution need to be exercised.

Specializes in Emergency, Case Management, Informatics.
.I still see this traveling down a path of lawsuits and poor care. I agree that the "I'm here for a pregnancy test" crap can then be triage else where....extreme caution need to be exercised.

ED's that go this route have likely spent a few moments with an attorney or two going over the legal and ethical issues involved, don't you think?

Specializes in ER, TRAUMA, MED-SURG.

Dang - Hey - the last facility I worked sounds a lot like the one ur describing. We started doing this about 9 months before I resigned - I had a CVA and stay home now. If I remember correctly, we --

Had an RN in triage; the decision was made regarding the need for the "big ER", Fast track, or possible screening and referred to PCP or clinic. The pt left triage and was immediately sent to the screening area. They were seen by a NP or PA. Most of the time, the screener had a nurse to assist, sometimes the triage nurse filled in when they could. We had the criteria posted regarding MSE and refer to PCP.

In the time I was there I got one phone call from my manager to come in due to a complaint. We had been reported to state (NEVER the kind of call u want to get!!!!) I went in and we met with two state people - it was a pedi pt ( 3 or 4, I think) - Mom stated her baby should have been in the ER and not just screened. Thank God!! my documentation as well as the NPs notes, ect got the complaint handled immediately.

Never want that phone call! Scare the crap out of u!

Anne, RNC

Specializes in ER, TRAUMA, MED-SURG.

Oh, as far as payment went, the ER billing people got to the ER chart and placed different colored papers on the front - saying which had to pay upfront or how much insurance co pay was needed.

Anne, RNC

Specializes in ER, TRAUMA, MED-SURG.
That's just wrong

You said it!!!! That is horrible! In the last 4 yrs, I've had a CVA, a small MI, onset of seizures (only a few) 5 cardiac caths and a trip to Ocshners in New Orleans, La for an ASD repair.

Dh works full time as a nursing supervisor at the same hospital - we have gotten behind on bills, unfortunately - and I'd be up "poo poo" creek if that happened here.

AnnE, RNC

I have no problem with this, if, as you stated, they have a viable alternative in going to the clinics.

Specializes in ER.

We did this at my last job. Typically screened out patients: bug bites, abrasions from minor accidents, possible STDs with no symptoms (my partner said), preg tests without any symptoms), gout with established hx, medication refills, medical evaluation before in patient detox, etc. Frankly, there are dozens of them when you add them up even when you are very liberal and call someone's vomiting "epigastric pain," you can still screen plenty of people out.

Patients also had to be between 12 and 65, have stable vitals, be ambulatory (so drama queen who insisted on wheel chair for her not even swollen ankle? You be seeing her!), etc. Frankly, its the right and fair choice for the patient. Why should they get a huge bill for care they don't need? The health department screens for STDs every day!

After they were screened, they were referred to financial services to pay before they got seen.

I guess I wonder how exactly a mid-level care provider doing an exam that complies with EMTALA will make things go more quickly. These exams will still have to happen somewhere, and this sounds a lot like urgent care to me, which we have in our ED. So the difference is that the patient gets told "yeah, looks like strep, pay now or go home" versus "yeah, the 5 minute rapid strep confirms strep throat, here's your scrip for abx"? Considering the fact that the rapid strep could have been done while the mid-level was seeing the previous patients waiting to be screened, it doesn't seem to me like much of a time saver (freeing beds and improving patient flow) or a money saver.

I would love people to start making better use of the ED: patients that cost the hospital money aren't job security when the hospital goes out of business or closes their ED, and I get plenty annoyed when people get huffy about when the doctor will hurry up and get to them to see their ringworm or hooha discharge or whatever, but I think making primary care truly accessible has to happen first. We have patients who come in who tried to get visits with their PCP who were told to go ahead and go to the ED because the doctor's office doesn't want to/can't deal with the sick visit volume, and our local free clinics are already busting at the seams, and primary care doctors aren't earning wages competitive with other specialties. EMTALA frustrates me sometimes, but when I look at the larger issues within the healthcare system....I'm glad we don't turn people away.

Specializes in Critical Care, ED, Cath lab, CTPAC,Trauma.

i came upon an article from medlaw.....a premir site for all things emtala lawsuit related information and case stuydies/advice that has been a staple for me and my travels in emergency medicine.

http://www.medlaw.com/

washington suits seeks to block state medicaid plans that may violate emtala and bba

the washington state chapter of the american college of emergency physicians has filed suit in state courts to block a proposed medicaid rule that would not pay for more than three ed visits per year that were deemed "non-emergencies". among the listed "non-emergencies" was chest pain and other "true emergencies" according to wacep. the ban would be based on final diagnostic codes.

in case the states have forgotten, there is a little matter of emtala requirements that pre-empt state laws that conflict, and hospitals cannot simply do what the states want them too. a state that gets a medicaid waiver does not have a waiver from the balanced budget act or from emtala. over the years, some states have taken the position that "they are not requiring hospitals to violate emtala, they simply are not going to pay them if they don't."

the new approach is not new at all. in the 90′s hospitals were getting crushed between managed care plans and medicaid on one side and emtala on the other, and cms was leaning on the states and citing hospitals left and right for emtala violations. the result was the balanced budget act in 1998. now, unless they slipped a repeal in obamacare that i missed ...after all, it was 2300 pages...it is directly applicable to this circumstance.

the rules that came out of that law were:

1. managed care plans and medicaid must pay for ed visits based on the "prudent layperson" standard of the presenting complaint. if a prudent lay person, given all the circumstances, would have thought it necessary to come to the ed for care, the plan had to pay regardless of the final diagnosis code. (certainly chest pain meets this standard.)

2. it banned "pre-authorization" requirements for plans and medicaid.

3. it imposed a $25,000 per patient visit violation on managed care plans and medicaid for violating the rules.

ed documentation problem

ed documentation frequently result in not getting paid under the prudent layperson standard because documentation of "ear ache", for instance, often omits details about attempts to see a doctor, deterioration, and associated complaints. this is frequently the result of the use of the shortest possible statement of chief complaint, lack of a detailed history, no observations about pain and other conditions on presentation, etc.

it is further complicated by short, judgmental documentation by triage nurses and ed physicians who would rather vent on "unnecessary use of my ed" than get paid. the less important the visit appears in the documentation, the less likely that the prudent lay person standard will be met.

http://www.medlaw.com/newblog/

i think that while in theory a great idea to "weed out" the abusers there are inherent dangers in hte exection of this ideal.......time will tell :cool:

Specializes in Critical Care.
I will owe $1000.00s on my hospital bill ! I hope I will not be bared from seeing my doctor ? How can they leagly do that ?

I spoke to the state insurance commissioner and was told since they self-insure they can refuse to treat you if you have unpaid bills even though you are still paying insurance premiums. Truthfully most large business now self-insure and that gives them a lot more leeway in what they can do and what they can choose to cover or not. They are not required to follow state legislation only federal for starters. I would rather give my premium money to a commercial insurance company that had to comply with both state and federal laws, instead there is no choice. We are required to take one of their self-insured plans, only difference between them is lower premium for outrageously higher deductibles and out of pocket. I really wonder how people afford it, especially families. There is no money left over after healthcare costs and that is why people have no retirement anymore!

I guess I wonder how exactly a mid-level care provider doing an exam that complies with EMTALA will make things go more quickly. These exams will still have to happen somewhere, and this sounds a lot like urgent care to me, which we have in our ED. So the difference is that the patient gets told "yeah, looks like strep, pay now or go home" versus "yeah, the 5 minute rapid strep confirms strep throat, here's your scrip for abx"? Considering the fact that the rapid strep could have been done while the mid-level was seeing the previous patients waiting to be screened, it doesn't seem to me like much of a time saver (freeing beds and improving patient flow) or a money saver.

I would love people to start making better use of the ED: patients that cost the hospital money aren't job security when the hospital goes out of business or closes their ED, and I get plenty annoyed when people get huffy about when the doctor will hurry up and get to them to see their ringworm or hooha discharge or whatever, but I think making primary care truly accessible has to happen first. We have patients who come in who tried to get visits with their PCP who were told to go ahead and go to the ED because the doctor's office doesn't want to/can't deal with the sick visit volume, and our local free clinics are already busting at the seams, and primary care doctors aren't earning wages competitive with other specialties. EMTALA frustrates me sometimes, but when I look at the larger issues within the healthcare system....I'm glad we don't turn people away.

I suspect it will go more quickly than rooming somebody, a nurse doing a secondary assesment, and discharge instructions being written. Even if it doesn't go more quickly that time, chances of a return visit for the same mosquito bite are slim. The current system rewards trivial visits, and encourages people to use the ER, rather than seek out options.

Some have posted the risk to the hospital of this limited assesment. No more risk than the same provider deciding not to do tests with a pt in the room.

I think the real question is whether a hospital ER has the responsibility to provide free unlimited care. If you work in an ER, you know this is fairly common. It should be common in our current structure, as it works well for the recipients- at least from their perspective. The problem is that it is A- a pretty expensive way to provide care, and B- can interfere with the ability of an ER to treat emergent pt's.

Look at it this way: If the money was coming out of your pocket, (it actually is) would you set up the current system as it is, or would you find a more cost effective way to treat non emergent patients with no money or insurance?

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