EMTALA

CA providers, officials fight over balance billing

Anne Zieger — Mon, 11 Aug 2008 10:43:50 -0400

The battle is on in California over the issue of when it's legal to balance-bill patients, with providers contending that they need to issue such bills when health plans underpay. The dispute comes because in that state, the law is apparently unclear on a key issue--whether providers who don't contract with a health plan can balance-bill patients who see them as out-of-network providers.

At present, the California Department of Managed Health Care is suing Prime Healthcare Services in an effort to stop the hospital network from billing patients for out-of-network emergency care fees. The DMHC contends that Prime illegally billed up to 6,000 Kaiser Permanente members for outstanding balances, as well as members of other health plans. (It doesn't help matters any, politically, that Prime has made a routine practice of dropping managed care contracts when it acquires a hospital, seemingly in an effort to get higher out-of-network reimbursement rates.) The DMHC argues that state law bans balance billing for emergency care because doctors and hospitals have an implied contract to treat patients in emergencies--as required by EMTALA--which gives insurers the obligation to pay for services.

Providers don't care for the DMHC's reasoning, according to AMA newspaper American Medical News. They say that under this interpretation of the law, health plans can unilaterally decide what they're going to pay, and are likely to pay unfair rates for emergency services. They note that balance billing for emergency services was found legal under a 2006 state appeals court ruling, which held that "contracting providers" who can't balance bill are only those with an actual contract.

Meanwhile, the DMHC continues to press forward with regs banning all balance billing, as mandated by Gov. Arnold Schwarzenegger (R) in 2006.

To learn more about this dispute:
- read this AMNews piece

Related Articles:
CA sues Prime Healthcare for balance-billing insured patients
CA law would ban balance billing for ED services
Schwarzenegger orders end to balance billing

South FL emergency depts cited for denying care

Anne Zieger — Tue, 01 Jul 2008 01:46:24 -0400

Five hospitals based in South Florida's Palm Beach County were recently cited for denying treatment to 30 patients entering their emergency departments last year. While these incidents reflect a relatively small percentage of the 450,000 emergency department visits that took place in the county in 2007, the incidents add up to a large number, part of trends which have made Florida the state with the largest number of patients dumping complaints to CMS.

The cases are also a good example of the stresses EDs are facing nationwide in finding specialists to treat some incoming patients. Incidents identified by CMS include a 24-year-old who waited 12 hours with an open leg fracture and bounced from hospital to hospital as none were able to find an orthopedist to treat the patient. A West Palm Beach hospital was cited after six gastroenterologists refused care to a jaundiced patient with a distended stomach and shortness of breath.

All of the hospitals involved in these incidents have attempted to remedy specialist shortages by paying specialists to go on call. Hospitals in the area have also attempted to work together to establish a regional call plan to route patients to locations where specialists are available, but the going has been slow given hospitals' and doctors' sensitivities over fairness.

To learn more about the problem:
- read this South Florida Sun-Sentinel article

Related Articles:
Hospitals working to avoid non-emergency ED care
Study: ED crowding affects care
Atlanta hospitals screen out non-emergent ED patients
Case study: AZ hospital posts ED wait times on website

EMTALA flexibility proposed to relieve on-call MD shortages

Wed, 11 Jun 2008 06:59:58 -0400

In a new Medicare hospital payment rule released in late April, CMS included a proposal clarifying its on-call policies under EMTALA. If finalized, the proposal would let a group of hospitals in a region designate one of them as the on-call site for a specific time period or service, rather than each struggling to keep up on-call coverage. For example, two hospitals could agree that for half of the month, one hospital would be the official on-call facility, while the other would serve that role for the second half.

In making such a proposal, CMS hopes to address the steadily worsening problem hospitals face with finding adequate on-call coverage by specialists. In 2005, the most recent year for which survey data was available, 73 percent of ED directors reported to the American College of Emergency Physicians that they were having trouble making on-call arrangements.

Regardless of what arrangements they made, individual hospitals with emergency departments would still be required to do a standard medical screening exam and have a plan for how to proceed if an on-call physician wasn't available. CMS wouldn't give preapproval to plans, but would review each plan if EMTALA violations arose after those plans were put in place. (The lack of pre-approval seems to me like a glaring problem--everyone wants a safe harbor determination in place when weighty federal violations may be in the offing-but we'll see, I suppose.)

To learn more about the EMTALA plan:
- read this AMNews article

Related Articles:
On-call payments for ED coverage challenged
MA hospitals bow to on-call pay trend
Trend: On-call shortage closing trauma departments

Hospital services pre-payment may loom large in future

Fri, 09 May 2008 06:59:59 -0400

Recently, we've covered a variety of news that touched on the issue of whether hospitals should get tough about collecting from patients prior to delivering care for elective procedures. Most of it suggests that this is a risky strategy, at least politically:

* The Wall Street Journal ran a very unflattering piece on the M.D. Anderson Cancer Center's decision not to treat a leukemia patient until she coughed up $100,000 in cash.

* Perhaps in response to the WSJ story--or others like it--the Minnesota legislature just passed a measure forbidding the state's hospitals from investigating a patient's medical debt prior to treating them.

* According to one blog, an ED surgeon recently was sued under EMTALA because he gave a patient a realistic estimate of costs during treatment and the patient went elsewhere.

This is a difficult situation, and it's going to get nastier, particularly if reform-minded types take over the White House this year. Why? Because historically, hospitals have been asked to carry many of the costs of system, and policy-makers don't always bear in mind that they don't have the resources.

On the other hand, hospitals aren't completely helpless. As our sister publication, FierceHealthFinance, points out, hospitals often can do much more to qualify patients for various forms of charity care and public assistance, as well as collect from self-pay patients after the fact. That, at least, is a start.

Other than that, I suspect it's time for even the least politically minded hospital executives among us to become active. Make your case on the local, state and even federal level. Otherwise, our political leaders may continue to assume--as some seem to now--that you're the bad guys. - Anne

When it comes to ED costs, nobody wins

Fri, 02 May 2008 06:59:59 -0400

As we all know, things can get pretty tense in the emergency department, particularly for patients who come in because they have no health insurance and can't go anywhere else.

Given the price of emergency services, it's hardly surprising that patients blanch--and possibly even check themselves out--when they find out just how expensive their care will be. Apparently, that's just what happened in one unnamed ED, where a patient with a serious hand injury walked out when a surgeon candidly shared the estimated cost of care (about $10,000 to $20,000). It's worth noting that despite the likelihood that the patient would never pay up, the surgeon didn't deny the patient care, and didn't insist on any form of upfront payment either. He only gave the patient bad news--the truth.

Still, when the patient went to a different emergency room, that hospital didn't discuss fees, but rather told the man that he'd work things out with the facility later. Now it seems the first surgeon is facing costly EMTALA charges. The second hospital has accused that surgeon of committing an EMTALA violation, arguing that quoting prices constituted a "barrier" to care.

Wow. Talk about a no-win situation. The surgeon, who may have merely been of a literal turn of mind, simply answered a question with the facts--which, realistically, were probably more than a sick, frightened patient could handle. The man, who probably wasn't uninsured for his own jollies, did what he felt he had to do. Meanwhile, the other hospital most likely absorbed the bill, which wasn't great for them, of course.

I'm not sure there's a big lesson here, other than that in the world of uninsured, injured patients, pretty much nobody wins. Until there's a nationally-implemented, reliable source of funding for people without coverage--perhaps even just those with catastrophic needs--otherwise well-meaning people will continue to be caught in this bind.

I'd love to think that the next election will be change on this front, but honestly, I doubt it. What do you think the solution is here? Have you come up with any middle ground on this front? - Anne

ALSO NOTED: FDA admits it can't afford to boost foreign inspections; Researchers test anti-smoking vaccine; and much more...

Fri, 02 May 2008 06:59:50 -0400

> The FDA has conceded that maybe, just maybe, it will need more money if it's going to do a good job of inspecting foreign drug manufacture sites. FiercePharma

> Swedish researchers are launching a study of a new vaccine which could help people stop smoking. FierceVaccines

> A group of Jacksonville, FL-area hospitals have begun to let their patients pay bills online. FierceHealthFinance

> Is it a violation of EMTALA to tell an uninsured ED patient what his treatment will cost? Apparently, it could be. Blog

And Finally... This hospital CEO says she's run a hospital previously... but won't say where. Yes, you read that right. Article