The Consultant

Emergency physicians: Become educators!
“Give me your tired, your poor, your huddled masses yearning to breathe free, the wretched refuse of your teeming shore. Send these, the homeless, the tempest-tossed to me. I lift my lamp beside the golden door.”

Medical Management Professionals

“Give me your tired, your poor, your huddled masses yearning to breathe free, the wretched refuse of your teeming shore. Send these, the homeless, the tempest-tossed to me. I lift my lamp beside the golden door.”

 

We all know the inscription on the Statue of Liberty, but doesn’t this sound like the sign that could be in every Emergency Department in America?

Let’s examine some recent history of facts impacting on Emergency Medicine revenue in this country. EMTALA (1985) mandates that every patient must receive a minimum of a medical screening exam.

Virtually every state currently has the prudent layperson definition of an emergency (Balance Budget Act of 1997) established and, therefore, presumably incorporated in payer contracts.

Virtually every state has prompt pay legislation established and, presumably, incorporated in payer contracts.

Where have we been, and where are we going? First, let’s step back a few years into the 1980s. In these pre-managed care days, assuming an ED practice had a reputable billing service (or hospital counterpart), submission of pro-fee claims typically and usually resulted in payment. The days of true, indemnity plans were arguably the best of times for reimbursement. If a practice was non-contracted, chances are it received anywhere from 90-100% charge reimbursement.

The first seeds of erosion of this stratosphere of reimbursement were seen in denials for not-authorized, non-emergent and/or non-covered services. These denials in the late 1980s and early 1990s were key factors in declining ED revenue. The gatekeeper concept within the exploding era of managed care caused horrendous problems for ED practices in terms of getting paid. These were the times of a constant stream of claim denials if/when the PCP had not issued a referral.

With the advent of prudent layperson legislation (1997) the industry changed once again as claim denials for non-emergencies, and not authorized visits declined dramatically. The insurance industry ever vigilant when it comes to cash, quickly rebounded, now initiating down coding of services; this was the start of payers failing to accept the legitimacy of the claim form and in some instances the ED record itself, as services were downgraded with consequent decreased payments. The extreme example here would be services down graded to screening services, to a consequent base rate reimbursement along with a contractual prohibition against patient balance billing when a contract existed.

The next phase, or body blow to Emergency Medicine was the ever-creative insurance industry’s requests for medical records to substantiate provider claims. It is important to keep in perspective here that the latter part of this era through the 1990s and forward coincided generally with the time frames covered in the class action settlements of the last few years. These settlements resulted primarily from insurance carriers’ inappropriate denials and bundling practices.

Where are we today? Medical necessity is the current battleground for EM as payers downgrade, delay, and /or deny claims. So let’s understand this. EM is the healthcare systems’ safety net, bound by EMTALA regulations to service all comers, 365 days/year and of course 24/7. The ultimate arbiter of the necessity of these services, however, is the insurance company representative, far removed from the entire process. Ultimately this historical continuum can be characterized as follows: Very good reimbursement to no reimbursement, to delayed reimbursement, to reduced reimbursement, or all of the above. What should an ED practice do to adjust to, and address these constantly fluctuating circumstances? Answer: Take control of the process and be an educator!

Taking Control – Get involved politically with your local, regional, state and national legislators. It is certainly questionable as to whether the Medicare fee schedule ever was and, today, ever will be an equitable schedule. At a minimum it is imperative the schedule’s annual impending decline be addressed and be fixed. Medicaid fee schedules vary substantially by state; none are what they should be but several have been impacted through strong lobbying efforts by Emergency physicians; it can be done.

When one shifts away from the governmental payers, practices vary dramatically as to how much they engage and interact with traditional commercial and managed care payers. This brings up the issue of non-participation and actually de-contracting in some instances. This is always a tightrope walk as inevitably issues of hospital pressure and patient public relations must be recognized and seriously considered. The point here is that every ED practice, from the fully independent private practice, to the academic teaching institution practice, and every version in between, should be involved in evaluating and addressing all payer contracting issues. In one way or another these contracts impact every Emergency physician.

Be an Educator – Traditional commercial and managed care contracts are filled with issues that omit, ignore, and/or violate basic tenets of Emergency Medicine. These contracts are basically constructed to apply to office based settings, with most being boilerplate templates placed in front of ED physicians or hospital administrators with a clear expectation there will be no questions nor objections. Many examples exist where the perspective of the ED practice must be explained to payer representatives. I note the following examples:

EMTALA regulations prohibiting discussions of payment prior to a medical screening exam. EMTALA is an issue often overlooked in these contracts.

Prudent Layperson Definition of an Emergency is sometimes totally lacking in these agreements.
Vaguely defined “coding policies” leaving an ED practice open to arbitrary bundling and other payment practices.

Claim submission parameters far too short which ignore the realities and vagaries of the ED setting and the ED patient; both are unique. Payers need to understand that a significant percentage of ED patients do not present insurance information in the ED, and commonly ignore several bills.

Poor reimbursement rates and poorly defined clinical scenarios resulting in far too much ambiguity as to what can reasonably be expected to be paid. Do not accept the Medicare fee schedule as the benchmark of reimbursement. It is far too risky a tactic and a trap to avoid. Your non-governmental, non-contracted payers represent your market rates.

Delegated Credentialing is the preferred methodology for ED physicians, not protracted credentialing processes that hinder, slow and generally wreck havoc with ED practice’s cash flow.

Contract terms should always include yearly rate increases, and should last no longer than three years. Most ED contracts are silent especially on yearly increases, and oftentimes are multi-year deals.

The significance of the ED physician being an educator in payer negotiations cannot be underestimated. It is imperative that ED physicians understand the deficiencies in these contracts in order to challenge them with clear counterpoints specific to the practice of Emergency Medicine. It is a matter of survival.

 

John Holstein has been servicing emergency medicine for 23 years, lecturing and publishing with such organizations as state ACEP chapters and the National Healthcare Financial Management Association. Holstein is the current Director of Medical Management Professionals.