Can Payors Require Pre-authorization For ED Visits?
Historically, the answer has been NO. You cannot even ask about the insurance provider before the MSE without risking citation, and especially if that results in the patient being delayed or not being seen at all.
CMS has not backed off that position, stating:
Section 1001 of the Affordable Care Act created a new Section 2719A in the Public Health Service Act (PHSA) that provides for fair practices of private health insurance plans and generally states that if a health insurer offers benefits with respect to emergency services, the following are required:
• There may be no requirement for preauthorization of services even if the emergency services are provided on an out-of-network basis;
• There cannot be administrative requirements or limitations imposed on emergency services provided on an out-of-network basis that are stricter than those imposed on in-network emergency services; and
• The amount of cost sharing expressed as a co-payment amount or a co-insurance rate for out-of-network emergency services cannot exceed the amounts imposed on in-network emergency services.
Thus, the Affordable Care Act adopted protections for individuals to ensure that they receive appropriate emergency care without concerns of undue payment hardship. Note that the definitions of “emergency medical condition” and “emergency services” in Section 2719A(b)(2) of the PHSA specifically reference EMTALA provisions at Section 1867 of the Act.