What if the plan looks at the final diagnosis codes and decides not to pay?
Payor refusal to pay for emergency department (ED) services because the payor views the diagnosis codes on the hospital’s bill to the payor as representing conditions that are “non-emergent”. In States where such payor practices have been under discussion, some hospitals and physicians have asked if a payor adopts such a policy, would the hospital’s and physicians’ EMTALA obligations also necessarily change. CMS has advised them that the EMTALA obligations would not change.
In accordance with 42 CFR 489.24(a), the hospital must provide an appropriate MSE for any individual who “comes to the ED.” If the individual is determined through the MSE to have an EMC, the hospital must provide stabilizing treatment or an appropriate transfer. The fact that the individual’s third-party payor may subsequently deny payment to the hospital or to the physicians involved, does not change the hospital’s or physicians’ EMTALA obligations.
Further, hospitals must assure that the EMTALA definition is used to determine whether the individual has an EMC. In accordance with the regulations at 42 CFR 489.24(a) (implementing Section 1867(e)(1) of the Act), an EMC is defined as:“(1) A medical condition manifesting itself by acute symptoms of sufficient severity (including severe pain, psychiatric disturbances and/or symptoms of substance abuse) such that the absence of immediate medical attention could reasonably be expected to result in—
(i) Placing the health of the individual (or, with respect to a pregnant woman, the health of the woman or her unborn child) in serious jeopardy;
(ii) Serious impairment to bodily functions; or
(iii) Serious dysfunction of any bodily organ or part; or
(2) With respect to a pregnant woman who is having contractions—
(i) That there is inadequate time to effect a safe transfer to another hospital before delivery; or
(ii) That transfer may pose a threat to the health or safety of the woman or the unborn child.”
COMMENT:
The payment standard under EMTALA is that of the “prudent lay person” — so if a normal lay person would consider that they need prompt medical care or assessment and under the circumstances that means the ED, the visit is reimbursable.
The primary reason many visits are not paid based on the diagnosis code is because the ED failed to document the elements that make this a reasonable visit that must be paid. If you “poo-poo” the visit and minimally document it, you are stuck with the final diagnostic code denial.
ADDENDUM: I am particularly interested in how payors are considering this diagnostic code approach since the Balanced Budget Act (circa 1999) specifically enacted the Prudent Layperson standard and banned denials based solely on outcome codes. While CMS correctly warns that it is not a permissible practice, it carefully avoids specifically mentioning the BBA source.