Washington state suspends Medicaid emergency department limits

The restrictions would have denied payment for nonurgent care received in EDs.

By David Glendinning — Posted April 6, 2012

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Washington state emergency physicians are claiming a victory with the governor’s decision to suspend a zero-tolerance Medicaid emergency department payment policy that was scheduled to kick in on April 1.

The American College of Emergency Physicians praised Gov. Chris Gregoire for putting a hold on the implementation of the policy, which would have denied Medicaid payment for ED care given to patients diagnosed with one of about 500 conditions deemed by the state to be nonurgent. State legislators approved the limits as a way to cut down on paying EDs for care that patients should be receiving in physician offices or other less costly settings.

ACEP and its state chapter warned that the exclusion list was too broad and would apply to many patients who legitimately believed they were dealing with emergency situations when they showed up at EDs. A prohibition on paying for the treatment of sprains in the ED, for instance, would affect Medicaid patients who needed to rule out the possibility that they had broken bones, the organizations said.

“We commend Gov. Gregoire for recognizing the flaws in this plan and for not only standing up for Medicaid patients but for all patients,” said David Seaberg, MD, ACEP’s president. “The proposed list of nonemergent diagnoses puts patients in danger and unfairly targets the poor and those in most need of care.”

Emergency physicians in the state said a more rational way to restrain Medicaid costs would be to educate patients and physicians about how to avoid unnecessary ED care. Physicians support the prudent layperson standard for emergency care, which dictates that a payer should cover ED care if a person had a reasonable assumption that he or she was dealing with an emergency situation.

At this article’s deadline, Washington state lawmakers were working to wrap up their 2012 session, during which ACEP was hopeful an alternative plan based on physicians’ input would be adopted. That proposal would require follow-up by primary care physicians with Medicaid patients who had visited EDs, install a database to track beneficiaries’ ED use and implement better case management techniques.

ACEP said it dedicated more than $150,000 through its Emergency Medicine Action Fund to fight the proposed limits on ED payment both in the statehouse and in the courts.

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