Coverage Denials Draw Ire of Emergency Docs

Medicaid officials in some states are denying coverage for emergency department visits based on final diagnosis codes rather than the symptoms that brought the patient in, according to the American College of Emergency Physicians (ACEP).

ACEP said cash-strapped Medicaid officials are increasingly implementing plans to deny payment for emergency department services if the patient is ultimately determined to have a non-urgent condition.

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, ACEP said in a press release.

State Medicaid offices are reportedly relying on the Billings algorithm, created by John Billings, JD, of New York University's Wagner School of Public Service, to determine which diagnoses are non-urgent and therefore don't warrant Medicaid reimbursement.

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Source: MedPage Today