EMERGENCY CARE: Regulation Prohibits Delayed Services
Health and Human Services Department officials will announce this week a new regulation barring hospitals from denying or delaying emergency room treatment for any patient "because a patient's health insurance requires permission before treatment." The AP/Los Angeles Times reports that the move is intended to strengthen a 1986 law that bars "patient dumping" by hospital ERs. While that law was mainly intended to ensure that uninsured patients with emergency conditions were stabilized before being discharged or transferred by hospitals, regulators say that people with insurance coverage are increasingly facing delays or denials of emergency care "while emergency room staff consult with health plans to see if insurance will pay." The regulation will mandate "immediate care whether or not insurance pays" (11/30). Judy Holtz of the inspector-general's office called the measure "our way of alerting hospitals and doctors about their legal obligations to provide emergency medical care to the plan members" (Wolf, USA Today, 11/30). To ensure compliance with the patient dumping law, hospitals violating the regulation will be subject to a $50,000 fine per incident. HHS Inspector-General June Gibbs Brown said, "Despite the terms of any managed care agreements ... federal law requires that stabilizing medical treatment be provided in an emergency."
American Hospital Association spokesperson Rick Wade applauded the expansion of the 1986 law, but emphasized that "it's not going to solve the problem of some plans deciding that they'll use preauthorization rules as a way not to pay hospitals." Karen Ignagni, president of the American Association of Health Plans insisted that insurers already voluntarily employ the "prudent layperson" policy, saying, "Our plans want to make sure our beneficiaries know that if they reasonably believe they need to go to the emergency room, they should go." But Ignagni noted that patients often use emergency rooms for primary care, and the new regulations will prompt her organization to boost efforts "to make sure patients are seeking care in the most appropriate setting." Indeed, the Times reports, "gray areas abound when health plans won't pay for emergency care and hospitals get stuck with the bill" (11/30).