Emergency docs blast Medicaid denials based on final diagnosis

Tools

Emergency physicians are speaking out against basing coverage denials on final diagnosis codes rather than symptoms, reported MedPage Today. Specifically, the American College of Emergency Physicians (ACEP) condemns using misleading results from a research tool to deny payment for emergency department services.

Health plans and state Medicaid officials supposedly are using the Billings algorithm to develop a list of non-urgent diagnoses, which won't receive Medicaid reimbursement. However, research designer Professor John Billings of New York University's Wagner School of Public Service said his research tool is not supposed to be used in individual cases to determine the appropriateness of ED use.

The ACEP cited the restrictive Medicaid ED policy in Washington state, which would stop payment for roughly 500 conditions, starting April 1. Emergency physicians noted that under the new policy, Medicaid patients will have to know what their diagnosis will be before going to the emergency department, FierceHealthcare previously reported.

"Many non-urgent diagnoses begin with symptoms that could indicate life-threatening emergencies, such as lower back pain that could also indicate a rupturing aortic aneurysm," ACEP President David Seaberg said in a statement Tuesday.

Seaberg warned that Medicare and private health insurers also may try to deny coverage based on final diagnosis.

Aiming to safeguard patients' emergency care coverage, the ACEP has been pushing for a national "prudent layperson standard" that would require health plans to cover ED visits based on an average person's belief that he or she may have a medical emergency. Such a standard would protect a patient with chest pain--a likely sign of heart attack--who may be diagnosed with non-emergent heartburn following a medical examination.

To learn more:
- here's the MedPage article
- read the ACEP statement
- read the FierceHealthcare article

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