Upfront payment for non emergent conditions

  1. 7
    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.
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  3. 58 Comments so far...

  4. 17
    I would hate to be the "care finder" when the first patient considered non-emergent drops dead from an MI or CVA.
  5. 3
    I'm kinda agreeing with the above poster. Who is to say what we see is not an emergency, is really an emergency in disguise? I don't think we'll ever change people who are frequent flyers, heck my soon to be father in law gets his prescriptions refilled at his local emerg. But then you have people like me who never go to emerg unless you know you have to.
  6. 24
    Quote from AngelicDarkness
    I'm kinda agreeing with the above poster. Who is to say what we see is not an emergency, is really an emergency in disguise? I don't think we'll ever change people who are frequent flyers, heck my soon to be father in law gets his prescriptions refilled at his local emerg. But then you have people like me who never go to emerg unless you know you have to.
    I think you guys missed the part about the mid-level making an assessment (Nurse Practitioner or Physician Assistant). They're not going to miss an MI or CVA. They're most likely going to defer relatively healthy people with relatively minor complaints (22 year old, no medical history, presenting with sore throat x 2 weeks and no other significant symptoms that would suggest meningitis, etc.).

    I'm on board with it. I briefly worked at a hospital where this was done for Medicaid patients and it worked. Sure, the patients get pretty upset with it, but it frees up your rooms for the actual urgent and emergent patients.

    The downside is that the uninsured won't be able to use the ED as their primary care, and will likely not be able to afford any other healthcare. This is where your "care finder" refers them to community resources/free clinics that hopefully exist in your area. However, the ED was never intended to be primary care anyway.
    JZ_RN, Vespertinas, flyingchange, and 21 others like this.
  7. 6
    Quote from Murse901
    I think you guys missed the part about the mid-level making an assessment (Nurse Practitioner or Physician Assistant). They're not going to miss an MI or CVA. They're most likely going to defer relatively healthy people with relatively minor complaints (22 year old, no medical history, presenting with sore throat x 2 weeks and no other significant symptoms that would suggest meningitis, etc.).

    I'm on board with it. I briefly worked at a hospital where this was done for Medicaid patients and it worked. Sure, the patients get pretty upset with it, but it frees up your rooms for the actual urgent and emergent patients.

    The downside is that the uninsured won't be able to use the ED as their primary care, and will likely not be able to afford any other healthcare. This is where your "care finder" refers them to community resources/free clinics that hopefully exist in your area. However, the ED was never intended to be primary care anyway.
    my thoughts exactly. ed is for emergencies. unfortunately, not every community has community resources or free health clinics, or reasonable transportation to these places. I volunteer at a free clinic, and we constantly have people calling trying to get transportation to us.
    here's hoping that more free clinics pop up.
    Vespertinas, MMaeLPN, JulieL, and 3 others like this.
  8. 7
    I have heard of some hospital systems doing this, Press Ganey be damned! There is typically more to it- kids under 12 or 16 are exempt, as are people over the age of 60- I can't remember the particulars but you get the idea. No one is going to miss the MI or CVA, this is for people that show up for STDs, uncomplicated URIs, rashes, etc ad nauseum.
  9. 7
    Quote from danggirl
    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.
    i think your hospital is traveling a slippery slope and granting themselves a very liberal view of the mse as per emtala regulations. who do you think will be held accountable when the non emergent "indigestion" turns into a stemi.......not the md to be sure...it will be the triage nurse who will be hanged! what do you mean by a "middle level provider"? if it is a pa or np then the triage nurse is off the hook and the pa/np will accountable and if they in their independent practice decide that is a calculated risk they are willing to take then so be it.

    the scope of medical screening exams (mse) under emtala is to provide a medical exam of sufficient scope as to reasonably be intended to determine whether an emergency medical condition exists, and includes all necessary testing and on-call services within the capability of the hospital to reach a diagnosis that excludes the presence of legally defined emc's. the term emc will be defined below. exams that are "complaint based" and fail to address affected and potentially affected systems and known chronic conditions have been held inadequate by cms.

    florida law also requires the exam to include all necessary treatment and surgery.

    federal law basically requires all necessary definitive treatment to be rendered and that only true follow-up care (maintenance care) may be referred to physician offices or clinics.
    triage of patients is not a medical screening exam
    and is not an acceptable substitute under emtala.

    your ed as a not for profit must also provide "free care" or forfiet their medicare/medicaid reimbursement and their tax exempt status. also as a part of emtala a patients ability to pay or not to pay cannot have bearing on their treatment or decision to not treat. i was around when hospitals pulled these stunts years ago and people died. there were very good reasons why these laws were inacted. they may think they have found a loophole but they are mistaken. they will willingly place a nurse at risk so as to save a few dollars and to throw under the bus when something goes wrong.

    1. based upon past citations by cms, advisory letters from cms, and past litigation, it is our considered opinion that a medical screening examination should contain the following elements:
    2. log entry with disposition
    3. triage record
    4. on-going vitals recorded
    5. oral history
    6. physical exam of affected systems
    7. physical exam of potentially affected systems and known chronic conditions
    8. any testing necessary to rule out the presence of legally defined emergency medical conditions
    9. use of on-call personnel prn to complete above
    10. use of on-call physicians prn to diagnose and stabilize patient
    11. resolution of abnormal findings or test results by normalization (serial values) or explanation of why they are not significant to the presentation
    12. discharge/transfer vitals
    13. adequate documentation of all above
    Last edit by Esme12 on Nov 14, '11
    TinyRNgrl, JulieL, AngelicDarkness, and 4 others like this.
  10. 7
    [color=#000089]cms written standards for designation for a non-physician for mse and transfer decisions are items 1 and 2, while the remainder are those that have been articulated in various citations and should be considered "critical concerns" when a cms review is undertaken:

    • the classification for qualified medical personnel other than a physician who is authorized to perform a medical screening exam in specified departments of the hospital has been approved by the board of the hospital directly or by board ratification of medical staff bylaws provisions. (the concept is that the board is privileging a non-physician to perform and extended role, much as a mid-level provider.)
    • the scope of designation must be within the scope of practice for the designated provider under state laws
    • job description for the role, qualifications, and competencies must be established
    • formal designation for approved individuals is contained in their personnel records along with proof of specific emtala training appropriate to their role
    • on-going documentation of competencies, qualifications, and quality review appears in the personnel records of designated individuals
    • a written protocol exists defining the authorized functions of the non-physician
    • the protocol must clearly define the point when a patient is considered beyond the non-physician's capabilities and a physician must complete the cme
    • the rules must provide that the physician backing up the non-physician doing the mse is readily available and is mandated to promptly respond to provide the mse upon call or request.
    discharge vitals and adequate discharge summary are necessary to support a discharge. un addressed complaints, unresolved abnormal findings, and undocumented or illegible discharge instructions are likely to be cited. full transfer documentation must support a transfer and justify the transfer under emtala.
    criteria for non-physician (qualified medical person --qmp)

    emergency medical conditions (emc's):

    the term emc is much broader under emtala than under typical medical usage. this is a significant underlying cause for many emtala violations. the term includes any condition that is a danger to the health and safety of the patient or unborn fetus; or may result in a risk of impairment or dysfunction to the smallest bodily organ or part if not treated in the foreseeable future; and includes a specific range of itemized conditions:


    1. undiagnosed, acute pain sufficient to impair normal functioning is an emc [editorial comment: pain scale of 7 or greater is commonly associated with this level of impaired function, but this will be judged retrospectively by cms based on patient version and outcome, so documentation is critical. a lower pain value may not be "safe"];
    2. pregnancy with contractions present is an emc -- i.e. legally defined as unstable;
    3. symptoms of substance abuse -- i.e. alcohol ingestion;
    4. psychiatric disturbances -- i.e. severe depression, insomnia, suicide attempt or ideation, dis-associative state, inability to comprehend danger or to care for one's self.
    federal law permits the obtaining of information in the routine registration qrocess, but the information may not be acted on -- i.e. no advance approval may be obtained from a third-party payer or employer.


    calls to insurance companies or employers have repeated resulted in citations for emtala violation. handing a phone to the patient and having them call their insurance has likewise resulted in citations. cms specifically states that third-party payers do not have the authority to authorize treatment and that hospitals that follow hmo and insurance company procedures and directions will be cited for emtala violations.

    patient transfers decisions may not be based on hmo/ppo direction or policy.

    cms 2003 regulations strongly endorse the oig/cms prior "best practices" (translate that to "what we expect...") but do allow some slightly wider latitude. the basics of the "best practices" are: name and one other identifier at triage
    1. patients who are not triaged to the back my have routine registration that does not discourage the patient from completing care (comment: if you have a conditions of admission form with guarantors, personal liability statement, and assignment of benefits, you are at risk for financial discussions and resulting patient departures. cms has indicated that any system that induces departures will be at risk for citation for violating emtala.)
    2. you may ask for insurance information and copy the card
    3. you are strongly discouraged from any financial discussions at this point
    4. if the patient asks about financial issues, you are to say that finances can be dealt with following care
    5. if the patient continues to insist, the best practices indicate that a financial person experienced in emtala should hold that conversation (comment: i strongly recommend that physicians and nurses not discuss any financial issues with the patient at any time)
    6. you may contact a physician for medical purposes at any time, but not for gatekeeper permission to treat (comment: private physicians should be contacted only where there is a documented medical need, and no request by the pcp to send the patient to the office should be granted.)
    7. you may contact the insurance company after care is initiated (although most now do not require that), but if permission to treat or admit is denied, you still must provide the care. (so why call?)
    8. it is not required, but is considered a prudent approach, to separate the financial face sheet from the treatment record, so the treating physician is not aware of denials or types of insurance.
    9. once the patient has had an mse and is stabilized and/or admitted or the patient is determined not to have any emergency medical condition under the law, completion of registration and financial discussions may occur without emtala restrictions.
    http://www.medlaw.com/handout.htm

    familiarize yourself with emtala/cobra before you accept any responsibility for this policy. it is a big deal!


  11. 2
    Quote from danggirl
    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.
    I have heard of hospital here that does what you are talking about they have a np in the waiting room . I have never been to this hospital so I do not know how they work it but my understanding the np makes the call if you are alould to go back or not . The person I knew said they try to avoid this er because they do not what to waist there time if they get sent home .

    Now I for one am not shoure what would happen if the np/ pa made the wrong call . I was once Triaged wrong but was in the back ASAP when it was found out . What if that had happen in the system use talked about ? I would have maybe gone home and died ?
    Selene006 and lindarn like this.
  12. 11
    as long as EMTALA rules are met I think this is good business practice. Maybe people can be re-trained to 1) manage chronic conditions; 2) have a PCP; 3) not use ER for anything other than emergencies. In other words, take some personal responsibility


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