Study: Nonurgent diagnoses aren't enough to deny reimbursement

Patients discharged from emergency departments with nonemergency diagnoses almost always have the same primary complaints as patients requiring emergency care or hospital admission, a study published today in the Journal of the American Medical Association found.

As a result, policies that deny insurance coverage for patients based on discharge diagnoses alone, including Medicaid in some states, penalize those who legitimately thought they had an emergency condition when they went to the hospital, the researchers concluded.

"Limited concordance between presenting complaints and ED discharge diagnoses suggests that these discharge diagnoses are unable to accurately identify nonemergency ED visits," they report said.

The JAMA article cited an example of a 65-year-old patient with diabetes who went to the ED with chest pain but was discharged with a nonemergency diagnosis of gastroesophageal reflux.

"Attempting to discourage patients from using the ED based on the likelihood that they would have nonemergency diagnoses risks sending away patients who require emergency care," the authors said in the article's comment section. "The majority of Medicaid patients, who stand to be disproportionately affected by such policies, visit the ED for urgent or more serious problems."

Washington state recently tackled the issue of high usage of EDs by Medicaid patients by implementing several best practices that reduced Medicaid ED visits by 23 percent in six months.

A report by the Washington Health Care Authority found that providing Medicaid patients written information about options for nonemergency care helped reduce ED usage, along with tracking frequent ED users. The report indicated a primary cause of ED overuse by Medicaid patients is inadequate access to primary care and preventive dental care, FierceHealthcare previously reported.

Some hospitals have adopted proactive approaches including taking primary care services directly to homeless families in shelters or on the streets, or to Medicaid patients lacking other primary care services. The hospitals are finding such services cost less than equivalent care in ED settings.

To learn more:
- read the JAMA article