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Citing Medicaid Limits, ED Docs Sue WA State

John Commins, for HealthLeaders Media, October 4, 2011

Because EMTALA requires emergency departments to examine patients seeking care, "we still have to see them and we have to make sure they don't have an emergency," Anderson says. "The problem is that sometimes it takes a full evaluation to figure out that this burning crushing chest pain is heartburn and not a heart attack. What the state is saying is yes by federal law you have to see them and do the work up, but when you're done with the work up, if it turns out it wasn't a heart attack then you aren't going to get paid for any of that."

Jim Stevenson, chief communications officer for the Washington State Healthcare Authority, says ACEP has "misrepresented a little bit" the new restrictions. "The code doesn't refer to all chest pains. It only refers to non-cardiac, non-specific, generalized chest pains," Stevenson says. "This is not someone who is coming to the hospital in the belief that there is an emergency. It would probably be someone who has been at the emergency several times before with the same complaint. Many of these un-generalized complaints do end up looking for narcotics as a treatment."

The Washington State Health Care Authority issued a statement explaining the new restrictions and noted that the three-visit limit would not apply to:

  • Children placed by the department in out-of-home care with foster parents, relatives, or other caregivers
  • Clients delivered to the ED by ambulance, police or EMTs.
  • Visits for mental health diagnoses or for clients seeking detoxification services
  • Visits that result in an inpatient admission, emergency surgery, or admission for observation. 

The authority said the program also created an "exception to rule" process by which hospitals can appeal non-emergency billings on the grounds of special circumstances.

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4 comments on "Citing Medicaid Limits, ED Docs Sue WA State"


Julie Lohman (10/18/2011 at 6:46 PM)
Medicaid has allowed their clients to receive this kind of care for years - they are not introducing an approach that would ease these clients into the new culture - the patients and the hospitals are going to suffer radically for the culture that medicaid allowed -It could be interpreted that they errored and the patient and hospital will be punished.

Louise B. Andrew MD JD (10/8/2011 at 5:46 PM)
This is a blatant attempt to cut costs in order to meet a state budget, by circumventing federal "prudent layperson" law and forcing Emergency physicians to assume financial responsibility for screening indigent patients for emergencies. The state provides no other mechanism to do so. Other federal law (EMTALA) requires that it be done. So ED's are left as the safety net, which also must eat the costs. Attempting to frame this as a drug seeking or ED abuse issue is disingenuous at best and ill-informed at least. It will probably take a few out-of-hospital deaths of Medicaid patients with so called "non emergent" presenting complaints to make this issue public enough that the law will be changed legislatively, if the lawsuit is unsuccessful at toppling an unsound, fiscally motivated, and basically unconscionable piece of legislation.

Lisa Barber RN (10/5/2011 at 4:33 PM)
This program discriminates against poor and rural areas that have limited number of clinic physicians and no Urgent care clinics available. This proposal will cause patients needing care to wait until they are much sicker before seeking care and end up causing the tax payers more money. As the director of a rural emergency department, most patients we see frequently have psychiatric issues or have learning dosabilities and have difficulty understanding the difference between clinic care and emergency care. They only know they need help.