Emergency physicians in Maryland last week petitioned the state to probe a pattern of reimbursement denials among HMOs that allegedly violate patient-rights laws.
The Maryland chapter of the American College of Emergency Physicians became the second provider interest group to formally complain that the state's HMOs are refusing to cover medically necessary treatment. The Maryland Association of Hospitals and Health Systems took similar action last month (April 27, p. 20).
The physician complaints have launched debate over the costs of documenting claims based on patients' perceptions of medical emergencies that turn out to be unfounded or less serious than first imagined.
Those issues eventually could spread nationally because all major bills percolating in Congress provide for reimbursement of emergency care based on a "prudent layperson's" judgment of what constitutes an emergency situation (See related story, p. 4).
In 1993 Maryland became the first state to pass a law defining a medical emergency prospectively through the eyes of patients rather than allowing insurers to base claim decisions on the hindsight of discharge diagnoses. Eighteen states now use a similar prudent layperson measuring stick (See chart).
Maryland law also prohibits HMOs from requiring pre-authorization for emergency services. And HMOs are legally required to pay for medical screening of any patient coming to the emergency room whether or not the problem is an emergency.
In its complaint to the Maryland Insurance Administration, the state ACEP chapter said it has forwarded clinical chart information matched to claims that were denied illegally or unfairly.
The charts, which include identifiable patient information, were sent in sealed packages from physicians at 13 of the state's 48 emergency departments and were not publicly disclosed. The physicians contend that the submissions document hundreds of cases in which HMOs denied claims that should have been covered.
"They're looking at a retrospective diagnosis code and deciding whether to pay the bill," said Lawrence Linder, M.D., president of the chapter and an emergency physician at North Arundel Hospital in Glen Burnie, Md.
Linder gave the example of a throat infection as a seemingly minor complaint that could be life-threatening in the context of underlying medical problems-a glandular disorder or AIDS, for example. He said billing clerks who are not trained to look for this kind of information often deny payment for necessary visits.
An official of the Maryland Association of HMOs, however, contended that billing officials often don't have the clinical chart information available to put the visit in context, because physicians don't submit it.
And HMOs can't be expected to go back to an emergency physician and ask for more documentation when a claim appears to be a nonemergency, said the official, who did not want to be identified.
But Linder said it's not fiscally sound for emergency physicians to send charts with every patient claim. Some cases, like cardiac arrests, are obvious emergencies, and others are obvious nonemergencies, he said.
Physicians should have to incur the cost of sending patient chart information only when necessary to back up the payment claims for emergency treatment, Linder said.
That stance could open providers to criticism, however, said a Tampa, Fla., emergency physician prominently involved in the national ACEP's push for federal expansion of the prudent layperson standard.
Physicians should always have to provide documentation of the initial emergency scenario to supplement discharge diagnoses, said David Siegel, M.D. "Insurers cannot be forced to make decisions in a vacuum," Siegel said. "If the insurance companies are not being supplied with adequate documentation, I agree it's a major problem."
But a Florida colleague, John Stimler, M.D., said routinely producing reams of new documentation could put emergency physicians at a disadvantage by introducing another opportunity for insurers to stall or deny claims because of incomplete paperwork. "You have to come up with a methodology that makes sense and doesn't overburden the whole billing process," said Stimler, a Jacksonville emergency physician.
"To provide documentation from head to tail would put us back 10 years," he said. "I'm afraid that's not the solution."
Five years ago, the challenge was to get the prudent layperson standard into law, Siegel said. But now the snowballing acceptance is making emergency physicians "victims of our own success" as the laws and regulations hit the implementation stage, he said.
In Congress, both the Democratic-sponsored Patients' Bill of Rights and the Republican-backed Patient Access to Responsible Care Act include the prudent layperson language, Siegel said.