Sunday, October 02, 2011

ACEP Sues Washington State over Proposed Medicaid Rules

Proposed List of "Non-Emergency" Diagnoses Includes Those with Symptoms of Serious Medical Conditions

The American College of Emergency Physicians (ACEP) this week urged the Centers for Medicare & Medicaid (CMS) to reject a list of more than 700 diagnoses that Washington State will treat as “non-emergent” for Medicaid patients, effective October 1. The list includes the symptoms of serious medical conditions, including chest pain, shortness of breath, miscarriage and abdominal pain. 

The state’s plan will limit Medicaid patients to three non-emergency visits to the emergency department each year, putting the most vulnerable members of society — including children — at risk of serious harm. Physicians in the state have offered to work with state officials to come up with a list of truly non-emergent conditions. 

“The list of conditions was generated solely by state Medicaid office over the objections of physician and hospital task force representatives,” said Dr. Sandra Schneider, president of ACEP. “The use of discharge diagnoses instead of presenting symptoms/conditions is a clear violation of the prudent lay person standard required for Medicaid managed care organizations. With Washington State having close to 60 percent of its Medicaid population enrolled in managed care, how will the state comply with the law? Also, what implications does this have for the millions of people who will be added as Medicaid beneficiaries as part of health care reform?” 

Specifically, ACEP asked CMS to ensure that the Washington’s State Plan Amendment:
  • Requires the state to create a notification system or website so providers will know that an individual has reached his/her third annual “non-emergent” visit,
  • Requires the state to ensure that patients who reach this status have access to viable primary care services before imposing this policy, and
  • Ensures the state does not apply this policy to managed care patients in violation of federal law.
“The symptoms of many of these medical conditions indicate life-threatening emergencies, and people with these symptoms should seek emergency care,” said Stephen Anderson, MD, president of Washington ACEP. “Not doing so could lead to severe illness, disability, and even death. Including conditions such as congestive heart failure, kidney stones, miscarriage, chest pain, and asthma is outrageous and dangerous.” 

The prudent layperson standard requires health plans to cover visits to emergency departments based on an average person‘s belief that he or she may be suffering a medical emergency due to the symptoms he or she is experiencing, not a final diagnosis. It is designed to protect patients who experience the symptoms of a medical emergency but who, after a medical examination and testing by a trained professional, are diagnosed with an acute care or non-emergent medical condition. 

“We understand the financial stress that states are under and we support efforts at the state and national level to link Medicaid beneficiaries to primary care practitioners, but those resources have to be available and accessible,” said Dr. Schneider. 

Dr. Schneider also said that hospital emergency departments are required by law to see patients, but then this state plan is requiring the services not to be paid. 

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