Recent Cases Spotlight Pressure to Admit ED Patients
Pressure on EPs to admit patients unnecessarily has led to litigation in some cases. EPs can protect themselves legally by:
- seeking clarification, and asking for requests in writing;
- ensuring they can see what’s billed in their names;
- determining if they can be fired without peer review and due process.
Recent lawsuits have alleged that hospitals billed for medically unnecessary inpatient admissions from EDs, and that hospital administrators pressured EPs to admit patients when the patients could have been discharged or observed.1
Whether an admission is “unnecessary” is easy to determine in retrospect, but that’s not always true at the time of the ED visit. “The entire admit/observe disposition is a chaotic mess that is often fueled by third-party payers,” says Robert B. Takla, MD, MBA, FACEP, medical director and chief of the emergency center at St. John Hospital and Medical Center in Detroit.
Often, it is not clear at the time of disposition that an ED patient doesn’t meet criteria for admission. This might become evident only after additional testing and/or treatment have been rendered.
“Chest pain that resembles unstable angina, with an equivocal [ECG] and negative biomarkers, may result in an admission with IV heparin and other standard of care treatment,” Takla says.
It may not be clear that this patient’s presentation was not of a serious cardiac etiology until additional diagnostic testing is performed.
“Initially, the history and exam warrant an admission to a telemetry bed with intensity of service and severity of illness consistent with an admission,” Takla says.
If pressured to admit patients inappropriately, even subtly, Takla says EPs should “always try to do what is best for the patient and involve them in decision-making. Anything else is unacceptable.”
EPs should not change their recommendation based on finances or third-party interference, he emphasizes.
“If the EP believes they are being asked to do something that is inconsistent with the patient's best interest, there is an obligation to go to their chief and seek clarification,” Takla says.
If indeed the EP is under pressure or asked to commit fraud, Takla says that “every EP should genuinely and honestly respond that they will 100% do what they believe is in the best interest of their patients. Requests to do anything else can be asked for in writing, and I will bet you no one will provide such a request.”
EPs Face Pressure
Andy Walker, MD, FAAEM, a Signal Mountain, TN-based EP who offers legal consultation on the defense of EPs, says unnecessary admissions are just one of the improper things EPs can find themselves pressured to do.
“Others include avoiding the necessary admission of undesirable patients, making inappropriate transfers, ordering unnecessary tests, overlooking inadequate staffing, and ignoring coding and billing fraud,” he says. Walker says there are two ways to make EPs more resistant to such pressures and cut down on fraud and abuse:
- Ensure EPs can see what is billed and collected in their names, so they can recognize if fraudulent coding and billing are going on;
- Make sure no EP can be fired without peer review and due process.
“Only those EPs who own their own practice as partners in an equitable, democratic, wholly physician-owned group are guaranteed peer review and due process, and are able to see what is billed and collected on their behalf,” Walker notes.
Academic EPs typically are guaranteed peer review and some kind of due process, such as a hearing, before being fired. But as employees, they usually have no idea what is billed and collected for their professional fees.
“Nevertheless, with so many eyes watching and a commitment to evidence-based medicine, fraud and improper pressures are rare in academia,” says Walker, adding that the same is not true for publicly traded staffing corporations.
Some employment contracts stipulate that EPs can be stripped of their medical staff privileges and fired without due process or peer review.
“Their contracts require them to waive all rights to due process,” Walker says. “So, while federal law says EPs must be shown what has been billed and collected in their names, any EP who works for a staffing company and asks for that information may be quickly fired without cause.”
EPs in such situations may find it difficult to resist pressures to make inappropriate admissions and transfers, or to report inadequate staffing or unresponsive on-call specialists.
“They are forced to choose between their jobs and doing the right thing, because they can be fired on a whim and have no recourse,” Walker says. “Being a partner in a physician-owned, democratic emergency medicine group is a completely different story.”
This is because a partner in such a group cannot be fired and ejected from the group without a majority or super-majority vote of fellow physician-partners. Thus, EPs get to make their case to peers and defend themselves against allegations of wrongdoing.
“EPs are far less likely to fire ‘one of their own’ for illegitimate reasons,” Walker adds. This gives EPs some insulation from improper pressures from hospital administration.
“This is one reason why it is better for both EPs and patients if EPs own and control their own practices, rather than being employed by corporations beholden to shareholders,” Walker argues.
- FalseClaimsAct.com. The United States District Court has unsealed a whistleblower lawsuit filed by North Carolina emergency room physicians against Health Management Associates And Emergency Medical Services Corporation, Jan. 3, 2014. Available at: . Accessed June 5, 2017.
Anything not in patient’s best interest ‘unacceptable.’
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