Online CPR Certification Blog

American College of Emergency Physicians says that Medicaid officials with cash problems have over time been implementing plans, which deny patients their right to get payment for any emergency service if it is determined ultimately that the patient is not in any emergency condition. A patient visiting a hospital, for instance, complaining about chest pain issues can be discharged after being diagnosed with heartburn. In turn, Medicaid can deny the hospital from getting payment for treating such a patient if he or she wasn’t diagnosed with an urgent condition, even where the doctor doesn’t know that the pain is being caused by heartburn and definitely not serious at all like a heart attack, after the patient visits the physician first.

Physicians over relying on Billings’s algorithm

When a patient simply walks into the hospital, physicians have no idea what the patient will be diagnosed with, says David Seaberg, president of American College of Emergency Physicians, through a press release. According to David, this applies even to conditions that are threatening to life and this is a violation of the prudent layperson standards that are designed with an aim of protecting the health coverage of patients during emergency care. Medicaid officers at the state level have been reported to be relying on Billings’s algorithm, designed by John Billions, of the New York University Wagner School of Public Service, seeking to determine diagnoses that are non emergent and, which don’t warrant any Medicaid reimbursement.

According to Billings, he never intended his tool to be used for individual cases like a mechanism or triage tool for determining if the emergency department uses it appropriately. Instead, he mainly developed the tool with an aim of determining if some patients who visit emergency departments could get treatment in primary care settings. The tool produces probabilistic estimates for a wide range of diagnoses that shows if patients visiting the emergency room having such diagnosis can get treatment in primary care settings or whether the medical condition is avoidable or preventable if effective and timely ambulatory care is given, said Billings in a press release.

Non urgent diagnoses for emergency Medicaid patients

ACEP noted that the Medicaid office located in the state of Washington, for example, has now created a list containing over 500 diagnoses that are considered ‘non- urgent’ for emergency Medicaid patients. This includes conditions like urinary tract infection, sprains and bronchitis that the state can’t reimburse hospitals. According to Jim Stevenson, from Washington State Health Care Authority that administers Medicaid program in the state said that state legislature directed his office to find ways in which non urgent visits to ED could be stopped and his office has been working tirelessly with hospitals and doctors trying to define this. Some protocols are being developed in the meantime by the Medicaid Office to ensure that doctors can now determine easily when a given patient has a condition that is non emergency.