Retrospective denial of emergency department payments is inappropriate

The ED is an efficient place to treat ED patients

The purpose of this study was to determine what percentage of ED patients would be more efficiently treated in an offsite clinic. A stratified sample consisting of 650 ED visits were reviewed. Patient care was classified as more efficiently delivered in ED or clinic using prospectively developed criteria. Five hundred fifty-three (85%; 95% confidence interval [CI], 82-88%) visits met the definition of efficient ED utilization. One (0.15%; 95% CI, 0.01-0.99%) met the criteria for efficient clinic utilization. The other 96 (15%; 95% CI, 12-18%) failed to meet the definition of efficient for either site; 92 of these failed 2 or more clinic criteria. Only 25 (3.9%; 95% CI, 2.6-5.7%) were seen for nonacute problems. Few ED patients would be more efficiently seen in a clinic.

Effect of state legislation prohibiting denial of emergency department patient claims

STUDY OBJECTIVE

On July 1, 1996, two Florida state laws were implemented to prevent denial of legitimate patient claims. Our objective was to determine whether the laws have been effective in reducing inappropriate denials as measured by the proportion of claims and charges denied.

METHODS

A comprehensive set of claims for in-state emergency physician services from a physician billing company were analyzed for the period January 1996 through June 1997, covering 6 months before and 12 months after the effective date of state legislation. The number of facilities included in the data varied from 55 to 67 (mean 63). Denials were classified into 6 categories by payer type. Gross denials were those claims that were completely not paid by the payer, net denials represented the amount denied after patient payments. Downcoding was not examined in this study. Main outcome measures were the proportion of claims and charges denied before and after July 1, 1996.

RESULTS

The classification of relative proportions of primary payers did not change appreciably over the study period. The proportion of denied claims decreased significantly (Kruskal-Wallis P <.001), starting 2 months after implementation.

CONCLUSION

After initiation of state legislation, payers continue to inappropriately deny claims, although the number of claims and total charges denied has decreased. In response to this legislation, payers are denying larger claims and patient copayments have increased.