Many Patients Worried Health Plan Will Not Cover ED Visit
Of 2,200 adults asked about concerns regarding an ED visit, 48% said they were “very concerned” about the cost of the visit, according to a survey conducted by the American College of Emergency Physicians.1 About the same percentage (47%) were “very concerned” their health insurance might refuse to cover the visit. For providers, there is no easy answer. “The provider won’t know what services the patient needs prior to evaluation, and won’t know if the patient is insured, has a copay, or [pays a] deductible,” says Patricia S. Hofstra, JD, a partner in the Chicago office at Duane Morris.
Well-meaning staff may tell patients, “You should be admitted as an inpatient, but your insurance won’t pay for your admission.”
“But if the patient refuses admission because of fears of being responsible for the bill, and it leads to a bad outcome, it could be legally problematic for the ED,” Hofstra warns.
It also would be an EMTALA problem if the patient was discharged before he or she was stabilized. “The provider should not initiate any discussion with the patient regarding payment for ED services,” Hofstra says.
If patients ask about it, Hofstra says that providers should document the patient was the one who initiated the discussion, the patient was told the hospital will work on the financial component of the visit after evaluation and stabilization, and the patient was told treatment will be provided to evaluate and stabilize, regardless of ability to pay. “The ED’s EMTALA policy should state that the patient will be evaluated and stabilized prior to requesting payment (or payment information) from the patient,” Hofstra offers.
Patients who express worries about the cost of the visit should be encouraged to stay until they are evaluated and stabilized. Some patients still insist they are leaving. In those cases, Hofstra says providers should ask the patient to sign a form stating they are leaving against medical advice before evaluation and stabilization and before requesting financial information.
“The signed form could be helpful in defending a malpractice claim as well as an EMTALA action,” Hofstra says.
It makes sense for EDs to be clear on this message: Patients have a right to emergency medical treatment regardless of financial status. “We now need to layer this with obligations arising under the No Surprises Act,” says Mary C. Malone, JD, a partner at Hancock Daniel in Richmond, VA.
The No Surprises Act requires providers to tell patients about their right to receive pricing information up front (i.e., a good faith estimate of the estimated charges for all expected services). Part of this estimate must include the estimated price of services rendered by all providers involved in the care continuum, regardless of whether those providers are part of the same system or practice. Also, these estimates must include discounts that are available, before services are scheduled.
It is somewhat unclear how all these particulars would apply in the ED, where care is unexpected. “Since the No Surprises Act is new, we will have to see how it plays out,” Malone says.
The No Surprises Act requires all health plans to pay for emergency services in the ED regardless of network participation. “But a patient might still receive treatment for non-emergency services in an ED,” Malone notes.
Emergency medical screening exams, stabilizing treatment, and appropriate transfers are requirements under EMTALA. None of that should be delayed by the process of gathering price estimates. “Responding to patient inquiries regarding costs of ED services, insurance coverage, or network participation has been a bit of a tricky area in the context of EMTALA compliance,” Malone says.
The EMTALA statute does not prohibit EDs from providing information on the cost of the visit, or whether the hospital is in network with the patient’s plan. “But we have to remember that the focus of EMTALA is ensuring access to emergency medical treatment, regardless of a patient’s ability to pay for it,” Malone says.
Answering tricky questions about the cost of the visit cannot interfere with the provision of care. “The sticking point is that EMTALA clearly provides that neither examination nor treatment can be delayed to respond to those questions,” Malone says.
That has not changed in many years, despite rising out-of-pocket costs for ED patients. In 1999, CMS issued a Special Advisory Bulletin to clarify recommendations on appropriate communications on payment issues in the context of EMTALA.2 “Although this Special Advisory Bulletin is more than two decades old, it still provides good guidance regarding how to respond to patient questions regarding payment issues,” Malone says.
EMTALA regulations were amended in 2003 to permit reasonable registration procedures (including addressing questions about insurance).3 Those questions can be answered before the medical screening exam is completed, provided that does not delay treatment in any way.
According to Malone, there are several ways EDs can avoid EMTALA violations. Do not post signs, or otherwise communicate to patients in any way, the hospital has created policies regarding prepayment fees for emergency services (including copayments or deductibles). Never allow a request for payment from the patient or the patient’s representative to delay the hospital from fulfilling its EMTALA obligations. If patients ask about the cost of the visit, respond with this: “We will obtain the information you are requesting as soon as possible. But you have a right to emergency treatment under the law, and we need to address your medical condition without delay.”
Additionally, train staff to carefully document discussions with patients regarding billing or payment questions. Ensure staff members understand patients are never implicitly discouraged from seeking emergency care in the ED (e.g., by stating another ED is in network with their health plan, noting there are shorter wait times at another ED). “Patients, not staff, should initiate discussions regarding payment for services,” Malone says.
REFERENCES
- American College of Emergency Physicians. Public opinion on the value of emergency physicians. August 2021.
- Bonner S. Update on EMTALA and managed care: HCFA issues special advisory bulletin. ED Management. March 1, 1999. https://bit.ly/3Kssaz0
- Lipton MS, Hayward LR. Summary of final changes to EMTALA regulations. J Med Pract Manage 2003;19:121-126.
Patients, not staff, should initiate discussions regarding payment for services. Train staff to carefully document discussions with patients regarding billing or payment questions. Ensure staff members understand patients are never implicitly discouraged from seeking emergency care in the ED.
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