In Indiana, we went to managed Medicaid some 10 years ago. I am the UM (utilization management) manager for 14,500 Medicaid lives in our capitated program.
Hoosier doc outlines ER-Medicaid process
The process goes like this:
- There are certain final diagnoses, which are always considered an emergency, although different plans can use different lists. And at least one plan has contracts that avoid all these reviews. They pay a flat fee for ER that is different dependent on final diagnosis.
- Then if not on that list, a lay person reviews the claim, and if that “lay person” thinks the visit was appropriate, it is paid.
- A nurse then reviews to see if extenuating circumstances existed to warrant an ER visit.
- And finally, if there is still uncertainty, a doctor reviews. In our network, that is me.
I review 30 to 50 cases a week. I usually approve only two to three of those, but remember, many have been approved before coming to me. We have all the internal data on actual approvals for emergency care. Approaches 80% appropriate, but at least 20% inappropriate. If the condition merits emergency, the claim is paid at Medicaid rates for the visit and any tests. If not, the hospital and the physician are paid a “screening” fee that is pretty minimal. EMTALA requires that every patient presenting to an ER have a screening. Therefore, we pay something for the registration and documentation of the screening exam. If no emergency exists, all the cultures for STD, flu swabs, X-rays or CT scans go unpaid. The only thing missing in all of this is the patient's responsibility and accountability to make wise choices about care. No penalty at all for ongoing bad choices, and a reward for going to the ER—no copays, service on demand and often lots of excess testing.
Dr. Bernard EmkesMedical director Managed Care ServicesSt. Vincent HealthIndianapolis
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