Citing Medicaid Limits, ED Docs Sue WA State
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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