Friday, March 2, 2012

New Medicaid Enforcement Worries Hospital Doctors

Some states are seeing an increase in a disturbing trend: Medicaid officials are denying coverage for emergency department visits because the final diagnosis of those patients is not considered to be an emergency situation. On paper, the concept makes sense. Why would Medicaid cover a patient going to a hospital for heartburn? The reality, however, is quite different.

For instance, a patient who comes to the hospital complaining of chest pain may be discharged with a diagnosis of heartburn. Medicaid could deny payment to the hospital for treatment of that patient based on the non-urgent diagnosis, even though a physician wouldn't know the chest pain is heartburn and not something more serious, such as heart attack, when he or she first sees the patient…

Medicaid is strapped for cash at the moment, and these decisions are a direct result of it. And while that is obviously a much bigger issue, we are already starting down a slippery slope. Now, hospitals are being forced to second-guess the handling of patients that exhibit symptoms shared by life-threatening and non-threatening conditions. According to Med Page Today,and an ACEP report, Medicaid is making these rulings based on the Billings algorithm, which Billings himself said was never intended to be used for this purpose.

It’s clear that something must be done to improve this situation, but what?

Obviously, hospitals want these new rulings to disappear. They’re currently working with patients under the looming threat that Medicaid payments won’t be approved. They are frustrated that Medicaid officials expect a patient to enter the emergency room with a diagnosis in hand – an obvious impossibility.

Meanwhile, Medicaid is desperate to cut spending, and denying emergency department payments for non-essential treatment seems like an easy fix. However, Medicaid has still done very little to address the ever-present (and growing) issue of fraud and overpayment.

What seems like the best solution to you? Should either side back down? Does the answer lie somewhere else entirely? Tell us in the comments below, and we’ll consider your responses in a future blog post.


Pam Argeris is a thought leader in the Healthcare Industry and possesses extensive, hands-on experience with CMS compliance, and multiple regulatory bodies such as NCQA, JACHO, and DOI. In her role at Merrill Corp., Pam focuses on developing solutions for compliance and quality assurance, delivered in a cost effective manner to improve beneficiary and prospect communications. You can contact Pam at

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