Billing may not be approved because the final diagnosis appears “fairly minor” compared to the presenting symptoms.
Emergency physicians often order tests or lab work to rule out serious concerns when treating patients. Insurance companies sometimes refuse to reimburse for that care based on the final diagnosis.
A Senate committee approved legislation to put limits on when and how insurance companies managing the state’s Medicaid plans can deny emergency physician service claims.
Senate Bill 242 applies what’s known as the “prudent layperson standard.” That standard requires insurance companies to provide coverage for emergency care based on symptoms, not the final diagnosis. For example, an emergency physician may give a patient with chest pains an X-ray, even if the final diagnosis was something like indigestion.
Dr. Daniel Elliott, with the Indiana Chapter of the American College of Emergency Physicians, said it’s disheartening trying to get reimbursed for the care emergency physicians provide.
“We treat and evaluate regardless of what shows up, what complaint it is, and without thought for reimbursement,” Elliott said.
Elliott said claim denials or reimbursement decreases can be particularly frustrating for small physician groups trying to remain in operation for their communities.
“They often don't even make sense with these denials, as oftentimes these are patients that are admitted,” Elliot said.
Dr. Elizabeth Struble, with the Indiana State Medical Association, said a lot of people don’t realize this is happening because it’s on the back end of the health care industry.
“There's a lot of things that happen often to rule out something that is really scary and come to find out that you have something that luckily is not that way,” Struble said.
But, Struble said that billing may not be approved because the final diagnosis appears “fairly minor” compared to the presenting symptoms. She said those symptoms can be complicated, have the potential to be life-threatening or may seem serious.
“We want to make sure that our emergency departments and emergency physicians are properly reimbursed for the work that they do, not just for the final outcome,” Struble said.
The Indiana Office of Medicaid Policy and Planning has a list of services on what is referred to as an “autopay list” for emergency care. Under the bill, insurers would not be able to deny claims solely because they are not on that list. Insurers would also be required to consider each claim based on the prudent layperson standard.
The author of the bill, Sen. Tyler Johnson (R-Leo) said the autopay list was a constraint that was a result of previous legislation.
The bill now heads to the Senate Appropriations Committee for consideration.
Abigail is our health reporter. Contact them at aruhman@wboi.org.
