title: Managed care organization authorization denials: lack of patient knowledge and timely alternative ambulatory care.
abstract: OBJECTIVE
  To assess patient knowledge of managed care organization (MCO) regulations, availability of alternative ambulatory care, and patient outcome after MCO insurance authorization denial for an emergency department visit.
  
  
  METHODS
  A medical screening examination and a follow-up structured interview were conducted with patients denied authorization for ED visits. The study was conducted at a large urban hospital with 36,000 annual ED visits and 40% MCO patients.
  
  
  RESULTS
  During a 7-month period, 151 patients did not receive MCO authorization for ED care. The interview response rate was 75% (104/138) with 13 patients excluded. Eighty-three percent (86/104) of respondents came to the ED because they believed their problem was an emergency. Four percent (4/104) of the respondents had been instructed to go to the ED but were later denied authorization, whereas 85.6% (89/104) did not know that the MCO could deny payment. Only 37% (38/104) of the respondents reported having received instruction on the MCO preauthorization process, whereas of the 19% who contacted their MCO as instructed, all resulted in scheduling difficulties. Although 57% (59/104) received follow-up within 24 hours, 11% (11/104) of the respondents had a subsequent return visit to the ED with a subsequent admission rate of 4% (4/104).
  
  
  CONCLUSIONS
  Few patients are aware of the need for MCO preauthorization for ED care, and almost half do not receive alternative care within 24 hours. A significant number of patients (11%) returned to the ED with an admission rate of 4%.
authors.affiliation: Resurrection Emergency Medicine Residency Program, Resurrection Medical Center, Chicago, IL 60631, USA.
authors.forename: K M
authors.initials: KM
authors.lastname: Viner
authors.forename: M
authors.initials: M
authors.lastname: Bellino
authors.forename: T D
authors.initials: TD
authors.lastname: Kirsch
authors.forename: P
authors.initials: P
authors.lastname: Kivela
authors.forename: J C
authors.initials: JC
authors.lastname: Silva
mesh_terms: D000293:Adolescent; D000328:Adult; D000368:Aged; D000369:Aged, 80 and over; D000553:Ambulatory Care / Q000706:statistics & numerical data; D002648:Child; D002675:Child, Preschool; D004636:Emergency Service, Hospital / Q000191:economics / Q000706:statistics & numerical data*; D005260:Female; D007722:Health Knowledge, Attitudes, Practice; D006786:Hospitals, Urban; D006801:Humans; D007223:Infant; D007231:Infant, Newborn; D007349:Insurance, Health, Reimbursement / Q000191:economics; D007407:Interviews as Topic; D008297:Male; D008329:Managed Care Programs / Q000191:economics*; D008875:Middle Aged; D016134:Organizational Policy; D016312:Treatment Refusal