Medicaid may stop covering visits to ER later deemed ‘unnecessary'

Medicaid soon might stop covering emergency-room treatment that state officials decide afterward was “not medically necessary.”

A state Health Care Authority rule putting a three-visit limit on unnecessary ER use by poor patients was blocked in court on procedural grounds. The agency has replaced it with a new policy planned to take effect April 1 that would reduce the number of conditions deemed non-emergencies but would forbid even a single unnecessary visit.

The doctors and hospitals who sued over the old rule blasted the new plan Tuesday, saying it would leave it up to a “faceless bureaucrat” to decide what’s an emergency. They weren’t ready to say they’ll go to court again over it.

Medical providers would foot the bill if they treat patients and the state doesn’t pay. They couldn’t bill the patients, as was possible under the old rule, the Health Care Authority says.

“The client is not at risk anymore for the ER bills,” said Dr. Jeffery Thompson, chief of the state’s Medicaid program. “This is invisible to the client. The client’s going to get treatment regardless.”

The move is part of an ongoing attempt by state government to crack down on excessive ER use. Other kinds of treatment have such limits, Thompson says.

He points to patients seeking ER treatment for diaper rash and other ailments better treated by a primary-care doctor, and to hospital frequent fliers who show up twice a day, as he said one patient with obsessive-compulsive disorder did recently. The hope is to divert such patients to other providers.

Lawmakers cut $33 million out of the state budget by demanding tighter ER rules for Medicaid, but now the full cut is unlikely to be achieved by the end of the budget period June 30, 2013. The HCA expects to be millions of dollars short of its savings target.

A judge ruled last year that the HCA hadn’t followed the correct rule-making process in establishing a three-visit limit on unnecessary ER use. But the federal Centers for Medicare and Medicaid Services later said the agency was within its authority to deny coverage, Thompson said. The state proceeded with a flat ban after the feds saw the three-visit limit as “problematic.”

There are no exceptions for special groups or ages in the new policy, as there were in the old rule.

“There’s no protection for foster children, the elderly, those that come from nursing homes,” said Nathaniel Schlicher, associate medical director for the emergency department at St. Joseph Medical Center in Tacoma. “They’ve stripped every patient protection out of this thing. It’s just frightening.”

Doctors say they are lobbying lawmakers to adopt an alternative plan to lower costs, with ideas such as organizing physicians to voluntarily agree to use a list of generic drugs. The HCA said it can’t bank on savings from a voluntary initiative.

Thompson said his agency also has removed some controversial conditions – “nonspecific chest pain,” for example – from a list of more than 700 targeted by the old rule. It culled the list down to about 400 conditions that the state now calls “examples” of what wouldn’t be covered.

Doctors say someone with a neck strain and ankle sprain that leaves them in a splint and crutches wouldn’t be considered to have an emergency. The HCA says that person would be covered if doctors use the correct billing codes; the agency plans to revise the list based on doctors’ feedback.

“True emergencies, we will pay for,” Thompson said.

For denials, the agency also will focus on people who are on a list of about 4,000 Medicaid patients who are known to overuse the emergency room, Thompson said.

Jordan Schrader: 360-786-1826 jordan.schrader@thenews tribune.com blog.thenewstribune.com/politics Twitter: @Jordan_Schrader