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Appropriations for “appropriate” visits: Payment denials for emergency department care

Published:December 27, 2017DOI:https://doi.org/10.1016/j.ajem.2017.12.061
      Recently, several large insurers including Anthem in New York, Kentucky, and Missouri as well as Blue Cross Blue Shield (BCBS) of Georgia announced policies to deny payment for visits to the Emergency Department (ED) retrospectively deemed “inappropriate.” These policies rest on the assumption that patients are misusing EDs for low-severity conditions that are more appropriately treated in settings other than the ED that are less expensive to insurers. While the particulars of these policies are still emerging–indeed, at least one prominent insurer was unable to provide any details of their program–the concept of dissuading ED use is not new. If history is a guide, these policies are unlikely to succeed. Previous attempts, most notably in the heyday of Health Maintenance Organization (HMO) in the 1990s, were stymied by patient harm from refusal of HMOs to approve or pay for emergency care [
      • Young G.P.
      • Lowe R.A.
      Adverse outcomes of managed care gatekeeping.
      ].
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      References

        • Young G.P.
        • Lowe R.A.
        Adverse outcomes of managed care gatekeeping.
        Acad Emerg Med. 1997; 4: 1129-1136
        • Kellermann A.L.
        • Weinick R.M.
        Emergency departments, Medicaid costs, and access to primary care — understanding the link.
        New Engl J Med. 2012; 366: 2141-2143
        • Raven M.C.
        • Lowe R.A.
        • Maselli J.
        • Hsia R.Y.
        Comparison of presenting complaint vs discharge diagnosis for identifying “ nonemergency” emergency department visits.
        JAMA. 2013; 309: 1145-1153
        • Hsia R.Y.
        • Friedman A.B.
        • Niedzwiecki M.
        Urgent care needs among nonurgent visits to the emergency department.
        JAMA Intern Med. 2016; 176: 852-854
        • Friedman A.B.
        The uncertain economics of insurance enabling more emergency department visits.
        Annals Emerg Med. 2017; 70: 226-228
        • Lee M.
        • Schuur J.
        • Zink B.
        Owning the cost of emergency medicine: beyond 2%.
        Ann Emerg Med. 2013; 62 (498–505.e3)
        • Horwitz J.
        Making profits and providing care: comparing nonprofit, for-profit, and government hospitals.
        Health Aff. 2005; 2: 790-801
        • Baehr A.
        • Martinez R.
        • Carr B.G.
        Hospital emergency care as a public good and community health benefit.
        Ann Emerg Med. 2017; 70: 226-228
        • Selevan J.
        • Kindermann D.
        • Pines J.M.
        • Fields W.W.
        Pop Health Mgmt. 2015; 18: 233-236
        • Butcher L.
        Offering Non-Urgent Patients Alternatives to Emergency Care.
        HFMA e-Bulletin, 2013 (accessed 26 December 2017)
        • Bailey J.E.
        • Pope R.A.
        • Elliott E.C.
        • Wan J.Y.
        • Waters T.M.
        • Frisse M.E.
        Health information exchange reduces repeated diagnostic imaging for back pain.
        Ann Emerg Med. 2013; 62: 16-24