Conflicts between managed care organizations and emergency departments in California.
To control costs, managed care organizations have begun to restrict the use of hospital emergency departments by their enrollees. They are doing this by educating enrollees, providing better access to 24-hour urgent care, denying preauthorizations for care for some patients who do present to emergency departments, and retrospectively denying payment for certain patients who use emergency services. Changing traditional use of emergency departments has resulted in conflicts between managed care organizations and these departments. Because federal law mandates access to emergency care for all persons, disagreements occur over the precise definition of an emergency medical condition. In addition, conflicts occur over the scope and payment for the medical screening examination required by federal law of persons presenting to an emergency department. Finally, issues arise related to the safety of patients who present to emergency departments and request care but are denied care because the managed care organization does not authorize the visit. Recent legislation in California has attempted to reconcile differences between managed care practices and federal and state laws; however, areas of continued conflict need to be resolved to prevent possible adverse consequences for patients actually needing emergency care.
Johnson
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Sutter Davis Hospital, Davis, California, USA.
Derlet
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D004636:Emergency Service, Hospital / Q000191:economics / Q000331:legislation & jurisprudence / Q000458:organization & administration*; D006801:Humans; D008329:Managed Care Programs; D012017:Referral and Consultation; D014218:Triage