Medicaid Shifts in Emergency Medicine: Collecting Revenue Amid Cuts

By Tyler Williams, Partner, Payor Logic
Twitter: @PayorLogic

Spring brings pollen, allergies and unpredictable weather patterns. Just as Spring ushers in seasonal change, payor reimbursement policies for emergency medicine follow a certain cycle. For April 2018, this pattern indicates a dip in Medicaid reimbursement as payors continue to target inappropriate emergency department (ED) visits and take money out of physicians’ pockets by cutting emergency medicine copays.

Efforts to keep patients out of the ED run alongside state-based initiatives to reduce Medicaid costs. When these initiatives combine, emergency medicine reimbursement gets tossed around like wildflowers in the April wind. Two recent announcements by the state of Kentucky may be indicators for additional Medicaid cuts for emergency medicine.

Kentucky Medicaid First to Move
In January 2018, Kentucky became the first state to be approved by the Department of Health and Human Services (HHS) to condition Medicaid coverage on work or work-related activities. Kentucky’s proposal, called Kentucky HEALTH (Helping to Engage and Achieve Long Term Health), changes the state’s Medicaid program for parents and non-disabled adults under 65. The program is slated to begin July 1, 2018 and includes provisions that impact:

  • Work requirements
  • Premiums and copays
  • Lockouts for failure to complete paperwork and report changes
  • Deductible accounts
  • Rewards accounts
  • Retroactive coverage
  • Non-emergency medical transportation

The same types of work-related provisions are common for unemployment benefits, but Kentucky HEALTH represents the nation’s first initiative to restrict Medicaid benefits in this way. Additional information is available from the Center on Budget and Policy Priorities.

As part of the same initiative, Kentucky’s Governor Matt Bevin announced stricter penalties for unnecessary ED visits and limits on the number of times patients can be seen before Medicaid won’t pay. Some Medicaid enrollees could even be fined for visits deemed non-emergent. More information about this specific component of Kentucky HEALTH was covered by National Public Radio (NPR).

Concerns for Emergency Medicine Reimbursement
The problem with these Medicaid deterrents is two-fold. First, there are differences in how the state, an emergency medicine physician and a patient define “non-emergency.” Patients with high blood pressure may be on the verge of having a stroke, but high blood pressure alone is not medical criterion for an emergency visit.

Second, limitations also fly in the face of the Emergency Medical Treatment and Labor Act (EMTALA) federal law requiring physicians to stabilize and treat all patients entering the ED, regardless of insurance status or ability to pay. Since an EMTALA violation could be a career-ending event for emergency physicians, the loss of Medicaid revenue will certainly take a back seat to appropriate patient care.

Emergency medicine physicians support non-emergent cases being treated by other providers and in more appropriate care settings. The specialty agrees on curbing patients from ED treatment when the visit is not medically necessary. However, when patients do present in the ED, emergency physicians must treat them.

Four Tips for Collecting Emergency Revenue Amid Cuts
The mission of emergency medicine practices is to offer the best care from start to finish. That includes collecting the bill. Amid Medicaid reimbursement changes and copay cuts, practices must implement the right processes, people and technology to ensure proper billing and reimbursement for the patients they treat. If the industry is curbing Medicaid benefits in emergency medicine, other governmental and commercial payors will also make reimbursement more difficult as described in Payor Logic’s August 2017 blog regarding eligibility exclusions.

Here are four best practices to receive every penny your practice rightfully deserves while also minimizing the cost to collect for Medicaid and other self-pay encounters:

  • Integrate demographic verification and insurance discovery into the up-front registration process.
  • Discuss Medicaid (and other payor) restrictions with the patient and their family. Many Medicaid patients are not fully aware of coverage restrictions. When possible, align your services with patients’ understanding of their coverage and any restrictions that apply.
  • For Medicaid and self-pay patients, determine propensity to pay before they leave the ED.
  • Focus your billing and collection efforts only on those Medicaid and self-pay patients with ability to pay.

This article was originally published on Payor Logic and is republished here with permission.