ER's Turn Non-Emergencies Away? - page 3

The below article appeared on the website of a local news station in Rock Hill SC. Some people in the community have varied opinions about this. For those of us "in the business", what do you... Read More

  1. by   mwboswell
    Quote from bjaeram
    If it's not an emergency your insurance may not pay. My husband recently went to the ER for dizziness and we got a letter from our insurance company saying it was not deemed an emergency and they would not cover the bill.

    This ticked me off because I am an ER nurse and I see all these freeloaders that come in for minor complaints and never pay a penny. My husband who was too dizzy to walk and has insurance couldn't get covered. I've never been so mad. I tried to appeal it but didn't get anywhere.
    I would appeal that to the hospital billing department. Point out that your insurance won't pay for "emergency" servcies and if they can re-code it and re-submit the insurance might pay it. Trust me the hospital/ED wants their money. If you make it clear that they are more likely to get the reduced fees from the insurance company if they re-code it versus if you have to pay out of pocket - they "may" just work with you.
  2. by   mwboswell
    Quote from HippyGreenPeaceChick
    There are not enough free or sliding scale clinics around. Then if perchance any workup is needed it is still faster done in an ER no matter how crowded it is. Then there are the local doctors who send their pts to the ER knowing we will get all these tests done quickly regardless of ability to pay. And get these patients admitted for them and they dont have to the work. It is the way our world works untill we get United Health Coverage for all.

    ...oh really?
    Do you really believe this?
    Please refer to the VA health care system as your prime example of "universal payor" healthcare.
  3. by   mwboswell
    Quote from Christina Wright

    Maybe it would be good if we could have a better referral system? Is it feasible for the hospital to work with the other clinics in the area to refer out non-emergencies instead of refusing care? Maybe give the patients options instead of denials?
    Good point.
    This would be the ideal situation, AND, I believe that any ED that incorporates the "non-emergencies-pay-first" policy, SHOULD have this type of referral mechanism in place.

    The ED's on military installations do just this (if their service lines are big enough). The ED triage nurse will check you, assess for an emergency and if not, they begin calling around to see where you need to go and get you an appointment time/slot (family practice, flight medicine, sick call etc.)

    But of course that's easier done in the military system especially with their differences in liability and malpractice. But when you see it work, it works well.
  4. by   mwboswell
    Quote from Crocuta

    We have a system coming down that I expect to start rolling out in the next year. We'll be building an interdisciplinary team that will review ED records and look for our major offenders and attempt to get them tied into more appropriate resources including PMD coverage. Part of it will be holding the line on narcotics and more aggressive use of medical screening exams for frequent fliers.
    .
    I "know" of a similar system already in place. It is headed by a "case manager" full-time RN. Her sole purpose is to identify "frequent flyers" or potential "ff's" and intervene while in the department assessing their long term needs and starting to work with them to find a "medical home". This also starts the process of identifying the pt with potential follow up "issues" and ER recidivism (sp?). From what I "hear" it's working great and has full buy-in by the medical directorship and nursing admin. Even got one long term FF onto HOSPICE care (as he was end-stage already) and this pt definitely benefitted by aggressive/apropriate pain control, better than he ever got during his twice weekly ED visits! He has passed on since then, but his final weeks/days had a whole lot less suffering and his passing was not a liability laden event which it could have been if he continued to frequently court the ER services.
  5. by   LHH1996
    mwboswell...you misunderstood and only took a piece of my post and ran with it. I MEANT by "it had to come to THIS" was, that people who abused the ER are why they had to make such policies in the first place. Hence the saying, "one bad apple spoils the whole bunch"
    i totally agree that people should not come to the ER for non emergancies..i guess i went off on a tangent because this subject reminds me that basically the whole health care system is a mixed up mess if you really think about it.
  6. by   Pixie.RN
    We have a similar case manager set-up in our system to identify the patients who are falling through the cracks. We work very hard to get patients to the appropriate follow-up, but sometimes they really just want to be seen in the ED, so they don't bother with follow-up, even if it's to our community health center that bills patients on a sliding scale basis.

    I'm sure the scenario in the article was more like a "real" ED visit -- the patient was triaged and placed in a patient room, and was then seen by the provider. The article presents it as if the patient was met at the front door by the doc and told to go away.

    I had a patient yesterday who was 9 years old, brought in by mom because he bumped his head. No complaints, no symptoms, not even a mark on him! He was seen by our provider, who explained to his mother why she wasn't going to order a CT head, and we discharged them with CHI instructions and told her what to watch out for. They left happy. But we did no more for her than the docs did for the person in the article ... of course, it's all in the presentation. In the article, they stated that they weren't going to treat her because it wasn't an emergency (according to the patient, anyway), and we told our patient we didn't need to do any tests at this time, but here is what to look for that would constitute an emergency.

    Some of our providers are holding back on prescribing narcs, too. We try to hook those folks up with pain management.
  7. by   mwboswell
    Quote from LHH1996
    mwboswell...you misunderstood and only took a piece of my post and ran with it. I MEANT by "it had to come to THIS" was, that people who abused the ER are why they had to make such policies in the first place. Hence the saying, "one bad apple spoils the whole bunch"
    i totally agree that people should not come to the ER for non emergancies..i guess i went off on a tangent because this subject reminds me that basically the whole health care system is a mixed up mess if you really think about it.
    Your first point is taken.
    But your second point - I don't share.

    I don't mind people coming to the ER for non-emergencies...so long as they can pay for my service and time. I'm just guessing here, but I'm thinking "non-emegencies" pay our labor/operating costs a lot more than "emergencies" do....

    A LOT OF US would be out of jobs if only "emergencies" came in.....
    Go figure.
  8. by   RedSox33RN
    I understand your point there, M Boswell, which I guess is why most ED's have Fast-Track areas now. It wasn't long ago that these weren't even thought of. Those are definitely non-emergent pts. Like you, I don't mind them coming and being seen there - they know the wait may be longer, but I don't want them taking up my last bed in the Main ED. The big question is if they will pay or not.....

    It really chaps my rear to hear patients tell me they can't afford their b/p meds/diabetic meds/tylenol for fever or pain, then see the cigarettes (or smell it on them) in the Coach purse, $300 Blackberry with bluetooth in the ear, kids playing PSP in $100 sneakers, hair and nails professionally done....I know we've all seen it. And yes, I've discharged many in w/c and brought them to the parking lot and seen the spouse's luxury SUV with spinner rims and expensive tires. It is all THAT kind of stuff the makes me mad. If you can't afford to pay me, sell that stuff.

    I do like the idea of evaluating those pts seen in the ED on a frequent basis. I question whether a lot of ours, if time was taken to set them up with a PMD or clinic, would comply. I sometimes think we, because of our new and improved "committment to customer service" are part of the problem. Some docs will tell pts they are using the ED way too much, but most just treat-n-street, no matter how many times the pt comes in. I had one the other day that has been seen over 35 times in 2009 alone in our ED. When will it end??? We have to be part of the solution, and I do agree with the OP article.

    I'm not doubting the woman in the article was in pain, but if she was evaluated (and I'm sure she probably was), there was nothing wrong with giving her a list of free-clinics or PMD's accepting new patients.
  9. by   Purple_Scrubs
    When I first read this thread, I thought "good for that ED, get those people who do not need to be there OUT!" Now with some recent personal experiences, I have a different perspective...

    I get kidney stones. I went to an ED with the first one, because even though I was pretty sure that is what it was, I needed the dx and I was in excruciating pain. Well, when I got the second one, I already knew what it was so I stayed home and managed my pain the best I could. Finally went to an urgent care when it did not pass on it's own. They only did a UA and said if it gets worse go to the ED :icon_roll. It did not pass in 5 days on its own, so I finally did end up in the ED to get a CT and see if it was too big to pass. It was not, and I actually passed it in the ED. Point: urgent care was virtually useless.

    My husband was having severe stomach pains that came and went. I suspect gall stones, so we took him to his PCP. Took bloodwork (which takes 1-2 days to come back), and sent him for an US and CT (which could take up to a week to get scheduled and results read). Recommendation: if the pain gets any worse, go to the ED. Point: PCP is virtually useless. (BTW, we still don't know what is going on, waiting for US/CT results.)

    So, I can see why people end up in the ED with serious but non-lifethreatening illness. I really wish I had taken DH to the ED, at least we would KNOW right now what he has going on. As it stands he has had this pain for 48 hours and we have no clue what is causing it. BTW, his PCP did not give him any pain meds or start antibiotics (pancreatitis is another concern). Like I said, useless.(We do have insurance and pay a $200 co-pay for ED treatment, then we still get bills for stuff that insurance does not cover. It is still better than waiting up to a week to get a condition diagnosed and treatment started. I don't want to wait until it IS a true life or death emergency!)

    Next time when it is myself or my family, I will be one of those non-life threatening cases clogging up the ED.
    Last edit by Purple_Scrubs on May 19, '09 : Reason: typo
  10. by   Katnip
    You're confusing emergency and life-threatening.

    Not all emergencies are life-threatening. Severe, sudden pain that doesn't go away with your usual at home treatment is considered an emergency. Kidney stones fit into that category. Sedond degree burns over a large portion of the body counts.

    However, if someone has a chronic problem and just go to an ED repeatedly for meds rather than a PCP who can then send to a specialist to actually fix the problem, well that's not an emergency. It's a convenience for them. Often it has nothing to do with whether or not they have insurance.

    Part of the problem is people don't want to bother making an appointment for follow-up because it takes too much time out of their day, or they don't want to think about it once the immediate pain/situation is taken care of-until the next time they get symptomatic and then it's off to the ED again for insta-relief.
  11. by   RedSox33RN
    Quote from Katnip
    Part of the problem is people don't want to bother making an appointment for follow-up because it takes too much time out of their day, or they don't want to think about it once the immediate pain/situation is taken care of-until the next time they get symptomatic and then it's off to the ED again for insta-relief.
    Exactly. And the ED is available when it's convenient for them. They can go after work or on weekends when the Dr office is closed.

    It ticks me off that a good portion of these same people can think far enough ahead to make sure they don't run out of beer or cigarettes, but not when they see they have one b/p pill left. Or that gee whiz, I've had this abd pain on and off for 6 months, but in those 6 months, can't remember to call to set up with a PMD, or even CALL their PMD if they have one, because we all know it will take a couple days to get an appt. And I do like asking pt's that - "So you've had this pain for 6 months and have been here 5 times for it, but haven't called your PMD about it? Why?" Pt: "Because they couldn't get me in."
  12. by   I_LOVE_TRAUMA
    The E stands for emergency. Anything else-make an appointment with the doctor. Where I work we would still have an abundance of work if only real emergencies were to come in. And it bothers me when people say that they don't have insurance and can't afford to pay as some of the others have said. Even McDonalds offers insurance, if you think there is even a remote chance that you or your family may get sick then you should have the either the means to pay and a pcp or free clinic in mind if you don't have the means to pay.

    I have always made sure myself and my children were covered in case we got sick, even when I was a very poor college student- I just got a second job if need be.
    A fellow student in my MSN program and I had a friendly debate about this not long ago. She was talking about being on welfare and getting finacial aid because how else was she supposed to get through school, and she also stated that it is a good thing that she was on welfare because her son was born premature and needed a lot of care and diapers and formula are expensive, and was she just supposed to let him die because he was sick and hungery...she wanted to know what brilliant ideas I had as a remedy... get a job with insurance, get a second job to pay your own tuition, and don't have kids if you can't pay for them (especially when you just told me that you can't pay for yourself).
    We have to remember that America is a society of needy, greedy, want- something-for nothings. I volunteer in a free clinic. The people that we see there that really are down and out or disabled come there like they are supposed to, are very grateful for the help we give, and are usually trying to get to a better place. Then we also have an overflow of people who are there bleeding the free ride to death, who are on disability, or welfare who EXPECT and feel they deserve free care, most of this population lives much better than I do. The poverty stricken/disabled are NOT overcrowding the EDs and taking advantage of government services, it is the pre-madonna, "It is an emergency because it is affecting ME"-types.
    I don't know what the answer is, but I am an Emergency Room nurse, when I go there I should be seeing life-or-limb threatening injuries only, I volunteer at the free clinic so that I can help those in need of chronic illness or acute, non-lethal ailments. I don't think we should have to educate the public about this-everyone knows this, they just don't care.

    I for one would love to work at an agency that had a policy like this! It would surely cut down on the "No, I didn't buy Tylenol for my kid because I am too poor" (but somehow I managed to get drunk/high today) and the "No I don't need a work note because I am on disablility for a severe back injury" (but somehow I managed to hurt my knee water skiing) types.
  13. by   mwboswell
    Quote from I_LOVE_TRAUMA
    The E stands for emergency. Anything else-make an appointment with the doctor. Where I work we would still have an abundance of work if only real emergencies were to come in. And it bothers me when people say that they don't have insurance and can't afford to pay as some of the others have said. Even McDonalds offers insurance, if you think there is even a remote chance that you or your family may get sick then you should have the either the means to pay and a pcp or free clinic in mind if you don't have the means to pay.
    So did you vote for Obama and universal health care?

    Quote from I_LOVE_TRAUMA
    and don't have kids if you can't pay for them
    Do you think she "chose" to have kids?

    Quote from I_LOVE_TRAUMA
    I volunteer in a free clinic. The people that we see there that really are down and out or disabled come there like they are supposed to, are very grateful for the help we give, and are usually trying to get to a better place.
    I'm going to pause and give you a big kudos here. MANY people who ***** and moan about "the system" won't get off their asses to do anything to help fix the problem or to contribute otherwise. So I sincerely applaud you for volunteering your time.

    Can I challenge you a step further to be involved with your local, state and national ENA (www.ena.org) to help work on some of these same problems? (Oh, and if you already are in the ENA and active then DOUBLE Kudos to you!!!! - you can rant on as much as you like!)

    Quote from I_LOVE_TRAUMA
    I don't think we should have to educate the public about this-everyone knows this, they just don't care.
    I wouldn't assume everyone knows this. I ask a LOT of my patients why they came to the ED for their problem, and a LOT of them say, becuase I need to get (insert name of problem/condition) "checked"..... I ask this quite a lot, and I hear this answer over and over and over.

    Besides, even G Bush doesn't know this, after all he said that we (Americans) had access to health care, jus to go the E.R.! So I think your statement is an over-generalization that people "don't know".

    Quote from I_LOVE_TRAUMA
    I for one would love to work at an agency that had a policy like this!
    Well see what you can do to get involved and suggest/promote this type of system at your workplace. Don't tell me it won't work at your place - the places that are doing it now used to say that and guess what! They're doing it; more and more places are. Just needs someone to start to champion change.

    Hey, I just wanted to say, don't feel like I'm tearing into your post. It's very obvious you have some emotional involvement in this topic and you are fired up about issues in your practice and workplace.

    Again, I strongly commend you for your community involvement - I sure wish more nurses would get involved at that level - OUTSTANDING!

    And I'm totally serious about the ENA thing - take your supercharged energy and influence and take it to the next level!

    Keep up the good work - thanks for the post.

    -Mark B.

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