What about other plan restrictions?
CMS comments included:
Payors restricting the number of consults that will be paid for during a hospital encounter/stay, including the use of consults for completing an MSE or providing stabilizing treatment of EMCs. Hospitals must not assume that such a coverage limitation by one or more payors would allow them to limit the services they are required to provide under EMTALA in accordance with 42 CFR 489.24(a).
Payors limiting the number of annual visits to the emergency department by a covered individual. Hospitals must not assume that such a coverage limitation means that they can limit the number of times they will provide an individual with an MSE and, if applicable, stabilizing treatment.
COMMENT:
There are two important concepts at play here:
1. The hospital must render required EMTALA care regardless of means or ability to pay.
2. CMS has always made the point clear — payors have no authority to dictate care.
In my experience with hospitals with payment issues, they don’t step up and challenge payment denials. The ones that frequently and aggressively challenge denials that are unjustified generally earn a reputation for being too much of a problem to play games with, and the payor moves on to randomly deny more claims from “soft” target hospitals.