As a provider in the acute medical setting, you have undoubtedly experienced the difficulty in obtaining prompt reimbursement for emergency and post-stabilization services rendered.
Imagine a situation in which a patient presents to the emergency department of your hospital with excruciating abdominal pain. The medical staff quickly triages the patient and begins running tests to determine the extent of the medical emergency. Upon review of the patient’s symptoms, lab results, and radiology reports, the treating physician diagnoses the patient with acute appendicitis. Fearing possible septic shock if gone untreated, the patient is rushed to the operating room to receive an emergency appendectomy. The surgery is a success, but the treating physician determines that post-stabilization care is required to improve and maintain the patient’s medical condition.
As the patient is monitored in the recovery room, the charge nurse contacts the patient’s Medi-Cal managed care health plan to inform the plan that their enrollee is not stable for transfer and the patient will be admitted to the Medical-Surgical unit to receive post-stabilization care. The health plan acknowledges the provider’s notification, issues a tracking or reference number instead of an authorization, or tells the provider that a case manager will return the call to authorize or disapprove the patient’s admission. However, the case manager never calls back (Under existing California law, after thirty minutes, post-stabilization services are deemed authorized). The patient is admitted to the hospital and the provider continues to maintain the patient’s clinical stability.
The next morning, the patient begins to complain of increased pain in the lower right quadrant of his abdomen. The treating physician orders a CT scan to rule out any post-operative complications. The resulting radiology report indicates that an abdominal abscess has developed after the patient’s appendectomy. The treating physician immediately places the patient on a high dose of intravenous antibiotics and the pain begins to subside. While the health plan has still not responded with an authorization, clinicals are faxed to provide an update on the patient’s condition.
Two days later, the treating physician determines that the patient can be safely discharged home. You immediately submit a claim to the health plan for emergency and post-stabilization services rendered to its insured. A week later, the health plan denies the entire claim because services were not “authorized.” The health plan requests complete medical records for the admission to determine the medical necessity of services rendered, despite the health plan’s forfeiture of its right to conduct a medical review when it failed to enter a disagreement of care prior to the commencement of the delivery of care, during the continuation of care and prior to patient discharge.
You now have two options: allow the health plan to conduct an unlawful medical review while it holds your reimbursement ransom, or forego tens of thousands of uncompensated medical dollars.
Too often, we see situations identical to the scenario described above. We have recently brought to the attention of the Department of Managed Health Care (DMHC) a large Medi-Cal managed care health plan’s failure to reimburse providers for emergency services rendered to its Knox-Keene enrollees, as well as its failure to assume care of patients and arrange for transfer when entering a disagreement of care regarding medically necessary post-stabilization services.
The health plan has failed to reimburse emergency services that were uncontested.
Under existing federal and state law, at a minimum, health plans must pay for those services provided by an emergency department, including a medical screening, examination and evaluation to determine if an emergency medical condition exists.
Per Health & Safety Code §1371.4, a health plan may not require an authorization for emergency services. Further, Health & Safety Code §1317.1(j) states that a patient is stabilized or stabilization has occurred when, in the opinion of the treating provider, the patient’s medical condition is such that, within reasonable medical probability, no material deterioration of the patient’s condition is likely to result from, or occur during, a transfer of the patient…
As these patients presented to our provider member’s emergency department, at a minimum, the health plan should have reimbursed the provider for the emergency services and care up to the point that the treating physician determined that the patient was stable for transfer. However, the health plan has failed to reimburse the provider for those emergency services and care rendered to these Knox-Keene enrollees.
The health plan failed to assume care of patients when denials were made while patients were still in-house.
In all of these cases, the hospital provider has kept the patient hospitalized to preserve continuity of care and has asked this office to advocate for the medically appropriate health care provided under California Business and Professions Code §510 and pursuant to Wickline v. State of California (1986).
Pursuant to 28 CCR §1300.71.4(b):
(1) A health care service plan shall approve or disapprove a health care provider’s request for authorization to provide necessary post-stabilization medical care within one half hour of the request.
Here, under existing state law, Knox-Keene licensed health plans are afforded two options upon initial contact from the provider requesting treatment authorization:
- Approve the request for authorization
- Disapprove the request for authorization
Pursuant to the above regulation, a denial of care is an automatic election to transfer the patient to another facility or plan provider as now a “disagreement of care” exists between the plan and the provider. When a disagreement arises, Health and Safety Code §1371.4 (d) strengthens the responsibility of the health plan as shown below:
(d) If there is a disagreement between the health care service plan and the provider regarding the need for necessary medical care, following stabilization of the enrollee, the plan shall assume responsibility for the care of the patient either by having medical personnel contracting with the plan personally take over the care of the patient within a reasonable amount of time after the disagreement, or by having another general acute care hospital under contract with the plan agree to accept the transfer of the patient as provided in Section 1317.2, Section 1317.2a, or other pertinent statute. However, this requirement shall not apply to necessary medical care provided in hospitals outside the service area of the health care service plan. If the health care service plan fails to satisfy the requirements of this subdivision, further necessary care shall be deemed to have been authorized by the plan. Payment for this care may not be denied.
As soon as a disagreement of care is entered, the health plan has a responsibility to assume care of the patient via transfer or having medical personnel contracting with the plan personally take over the care of the patient.
This did not happen.
The health plan has attempted to perform an unlawful retroactive medical review for statutorily deemed authorized post-stabilization services.
Pursuant to 28 CCR §1300.71.4(b):
(2) If a health care service plan fails to approve or disapprove a health care provider’s request for authorization to provide necessary post-stabilization medical care within one half hour of the request, the necessary post-stabilization medical care shall be deemed authorized. Notwithstanding the foregoing sentence, the health care service plan shall have the authority to disapprove payment for (A) the delivery of such necessary post-stabilization medical care or (B) the continuation of the delivery of such care; provided, that the health care service plan notifies the provider prior to the commencement of the delivery of such care or during the continuation of the delivery of such care (in which case, the plan shall not be obligated to pay for the continuation of such care from and after the time it provides such notice to the provider, subject to the remaining provisions of this paragraph) and in both cases the disruption of such care (taking into account the time necessary to effect the enrollee’s transfer or discharge) does not have an adverse impact upon the efficacy of such care or the enrollee’s medical condition.
(3) Notwithstanding the provision of Subsection (b) of this rule, a health care service plan shall pay for all medically necessary health care services provided to an enrollee which are necessary to maintain the enrollee’s stabilized condition up to the time that the health care service plan effectuates the enrollee’s transfer or the enrollee is discharged.
In this scenario, the health plan’s right to perform a review of medical necessity was waived after it failed to provide authorization or disapprove of the requested care and assume care of the patient via transfer prior to the commencement of care or during the continuation of such care. If a disagreement of care is not entered prior to the patient’s discharge, the health plan is prohibited from conducting a retroactive medical review. Without objection from the health plan, the treating physician has the right to control the patient’s care until the transfer or discharge of the patient. Thus, the health plan’s request for medical records is unlawful and contradictory to its obligations to reimburse uncontested emergency and statutorily deemed authorized post-stabilization care.
The statutes and regulations described above are intended to preserve a provider’s ability to render medically necessary health care services while preventing financial considerations from affecting their patients’ well-being. However, when a health plan fails to uphold its obligations in authorizing care or assuming care of patients upon entering a disagreement of care, a provider is faced with a difficult decision: discharge the patient against their own medical opinion, or jeopardize the solvency of their practice by providing services that may never be compensated.
To ensure a provider’s ability to practice medicine, ERN Enterprises and its subsidiaries, The National Council of Reimbursement Advocacy (NCRA) and The Reimbursement Advocacy Firm (TRAF), will continue to address a health plan’s violations that imperil our most vulnerable citizens and defend a provider’s right to advocate for medically appropriate healthcare for their patients.
Please notify this office of any cases involving Medi-Cal/Commercial/Medicare Advantage HMOs or PPOs engaging in trends similar to those described in this advisory, including:
- Failure to reimburse uncontested emergency services
- Failure to reimburse statutorily deemed authorized post-stabilization services
- Failure to assume care of patients via transfer upon entering a disagreement of care
- Attempts to conduct retroactive medical review for statutorily deemed authorized services
Although laws may differ from state and jurisdiction, we exist to establish a strategy that allows you to preserve the continuity of care for your patients in the face of insurer prejudice.
Contact Daniel Muhlbach, Claims Compliance Auditor, with any questions, comments, or concerns regarding these and similar matters.
Daniel E. Muhlbach, Claims Compliance Auditor
(714) 995-6900 ext. 6970
This post was written by ernncra