Reasonable’ registration still guideline for CMS

But what exactly does that mean?

New regulations regarding the Emergency Medical Treatment and Labor Act (EMTALA) notwithstanding, patient access managers continue to seek clarity on exactly how much registration activity may take place in the emergency department (ED) before a patient’s treatment is completed.

One common concern has to do with whether, and if so, to what extent, registrars can proceed with information gathering after a nurse triages the patient — getting a brief history, vital signs, doing a cursory assessment and categorizing the condition as emergent, urgent, or nonurgent — and the person is placed in a treatment room or returned to the waiting area to await space.

According to Stephen A. Frew, JD, a longtime specialist in EMTALA compliance, the comments associated with the new regulations emphasize that the Centers for Medicare & Medicaid Services (CMS) remains committed to the Office of the Inspector General’s (OIG) advisory that allows "reasonable" registration, forbids prior authorization, and forbids practices that raise financial barriers before the completion of the medical screening examination (MSE).

The full text of the OIG position is found at Frew’s web site, www.medlaw.com/oig.pdf.

Best practices?

Although the OIG position refers to "best practices," says Frew, a risk management consultant for Physicians Insurance Co. of Wisconsin in Madison, these descriptions should not be construed as being merely suggestions. The so-called best practices, he notes, have been applied as the site review standard in past visits.

His experience with citations issued before and after the OIG regulations and guidelines, Frew notes, is that they are enforced as follows:

1. Before triage, the hospital may obtain the patient’s name and one identifier — date of birth, address, or Social Security number, etc. If a clerk (registrar) takes this information, he or she must have no discretion in assessing the severity of the situation, and all patients must be presented to triage as quickly as possible Allowing any discretion on the part of a clerk, security guard, etc., as to whether the patient is to go to triage or register first is likely to generate a violation, he emphasizes.

2. Triage is provided following the triage protocol adopted by the hospital.

3. The patient is triaged directly to the treatment room or to the waiting area.

4. Waiting area patients may be registered to the extent of basic demographic information and may be asked if they have insurance. If so, Frew says, it is OK to copy the insurance card or get the name of the company, but the process must not delay care or put any financial pressure on the patient. Registrars may not discuss insurance coverage by saying, for example, "We will see you, but did you know your insurance does not pay here," or "Have you contacted your insurance company to get permission to be here?" Additionally, he says, registrars may not contact the insurance company for preauthorization or confirmation of coverage at this point. This includes public aid, Frew points out, regardless of any agency rule to the contrary.

5. If the patient goes directly back to the treatment area because of acuity, registration should wait until the MSE has been completed and stabilizing care has been started. Obtaining information or financial guarantees, and nonessential inquiries should be deferred until that point, he says, and that applies to questions to family members, as well as to the patient. Financial pressure on the family is just as likely to influence care, Frew points out, and also is likely to generate the financial discrimination complaints that lead to investigations and citations.

6. CMS may allow treatment authorization calls to be made following the MSE and while admission and surgery or other stabilizing care is being arranged or delivered, but the care must be rendered regardless of what the insurance company, gatekeeper physician, or agency says. Since most insurance allows reports within 24-72 hours of a visit, he notes, there is no good purpose for making an immediate call. Once an insurance denial is in the record, Frew says, it casts a pall of cynicism across all subsequent care decisions. If such calls are made, or if financial information is automatically called up by the computer system from past visits, it is best to separate the face sheet from the patient care chart, so that clinical decisions cannot be influenced by the information.

7. Once the full MSE has been completed, the decision to either admit or discharge the patient has been made, and the disposition of the case has been entered in the record, it is generally safe to get full financial data prior to discharge or as an element of admission. If a patient raises questions about financial coverage, Frew says, the OIG suggests those questions be deferred until after the MSE, or if the patient insists, that a financial counselor trained in EMTALA requirements be available. Some hospitals have such patients sign a waiver saying it is their choice to have that discussion before necessary care, he notes.

Frew cautions that CMS will take the patient’s version of a discussion unless it is fully documented to support the hospital. He recommends that physicians and nurses never discuss financial issues with patients.

The bottom line, Frew indicates, is that even if what you do actually produces no delays in care, that’s not good enough. CMS looks at whether your system has the potential to delay patients or put financial pressure on patients.