Bulletin Details

No. 4089: March 15, 2012


Medicaid Emergency Room (ER) Visit Limit


Background: As WSHA reported previously, the Health Care Authority is planning to stop paying for all Medicaid hospital ER visits it deems “not medically necessary” starting on April 1, 2012.  The Washington Chapter of the American College of Emergency Room Physicians (WA-ACEP), the Washington State Medical Association (WSMA), and the Washington State Hospital Association (WSHA) are continuing to fight this proposal, which would deny payment for any emergency room visit if the discharge diagnosis appears on a screening list. 

Legislative Update:  On March 1, 2012, representatives from WA-ACEP, WSMA, and WSHA met again with key legislative, gubernatorial, and agency staff to craft a legislative alternative to this policy.  We have drafted a budget proviso which has been included in the budget approved by the state House of Representatives.  The Washington State legislature reconvened in special session on Monday, March 12 to continue to work on the budget, and we are working to get the Senate to agree to this language.  It is uncertain how this will turn out.

The budget proviso gives hospitals the chance to avoid the no-payment policy by complying with seven “best practices” to reduce unnecessary ER use.  If a sufficient number of hospitals do so by July 1, 2012, we will avoid the no-payment policy.  If not, the no-payment policy will be implemented on July 1.   We are working with the Authority to better define these best practices.  If the proviso is included in the final budget, hospitals will have a very short time-frame to implement the best practices.  We should know within a few weeks whether the proviso has been included in the final state budget.

Agency Update:  Since no one knows whether the budget proviso will pass or not, hospitals need to be prepared for implementation of the no-payment policy on April 1, 2012.  The Authority announced in a meeting on March 13 that there will, in fact, be exceptions  to the no-payment policy.  Hospitals may request expedited prior authorization or retrospective authorization if the patient has been referred by a primary care physician; if there are abnormal vital signs on presentation; if a traumatic event, such as a motor vehicle accident, has occurred; and in other specific circumstances.  

The Authority has also released a new screening list with 434 diagnoses considered “not medically necessary.”  The Authority tells us it will distribute the billing instructions for the no-payment policy by March 16, 2012.  We will distribute these instructions to our members as soon as they are available.   Finally, we plan to  conduct a webinar with a representative of the Authority the week of March 26 to educate our members about this change in policy.

Legal Update:  We are continuing to explore whether denial of Medicaid payment based on the use of a screening list is legal under federal law.  We believe there may be grounds for a legal challenge if the state implements the no-payment policy. 

For additional information, please contact Barbara Gorham, barbarag@wsha.org or (206) 216-2512.


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