Health plans in Maryland have refused to pay emergency room charges "in many cases" even though patients had good reason to believe their health was in danger, a study by state insurance regulators has found.
But the health plans aren't to blame because they were not given sufficient information about the cases, the study by the Maryland Insurance Administration concluded.
The study shows that one of the key laws enacted to protect Maryland patients in the age of managed care--a measure that spelled out when health plans must pay for emergency room visits--isn't working as intended.
The 1993 law was written to address cases in which patients go to emergency rooms because they are experiencing what they believe are medical emergencies, such as chest pains--only to have their health plans reject the bill because the diagnosis turns out to be something as mild as indigestion.
Maryland was among the first of many states to legislate that health maintenance organizations must pay emergency room charges as long a "prudent layperson" had reason to believe his or her health was in serious jeopardy--regardless of the eventual diagnosis.
The MIA found many cases in which coverage was denied "for care that did constitute an emergency," state Insurance Commissioner Steven B. Larsen said in a news release this week.
When health plans reject emergency medical bills on the grounds that there was no emergency, patients can be left on the hook for unpaid charges.
In seeking the investigation, Maryland emergency room doctors had alleged that health plans routinely were violating the law. But a year and half later, Larsen has placed the blame elsewhere, citing "lack of communication between insurers and health care providers" and flaws in Maryland law.
The "failure to reimburse was reasonable because the billing information submitted to the health plans did not contain sufficient information to demonstrate that the case was an emergency," Larsen stated, adding that the study found no instance in which a health plan broke the law.
The crux of the problem is that the claim forms submitted by emergency room doctors do not show the symptoms that prompted the patient to visit the emergency room, Larsen said in an interview. As a result, health plans reviewing the claims have no way of knowing whether the patient was justified in thinking emergency care was needed.
The legally required form includes no space for such information. What's more, state law could be interpreted as prohibiting health plans from asking for additional information as a condition of payment, Larsen said.
Lawrence Linder, president of the Maryland chapter of the American College of Emergency Physicians, disputed that interpretation and complained that when doctors offered to give health plans more details about emergency cases, "they actually told us not to bother--they wouldn't read it." Linder said his group was "frustrated and disappointed" with the study's conclusions.
The insurance administration reviewed 833 cases submitted by Linder's group involving emergency room visits from January 1997 to March 1998. By far the largest number of cases involved Rockville-based Mid Atlantic Medical Services Inc., followed by United Healthcare of the Mid-Atlantic. Illegible records, lack of jurisdiction and other factors prevented the insurance administration from reaching conclusions in all but 267 cases.
Medical records showed that about 40 cases met the "prudent layperson" definition of an emergency, Larsen said. In another 40 cases or so, records showed that patients had gone to the emergency room at the direction of their primary care physician, Larsen said.
In one case where a claim was denied, the diagnosis was neck sprain, but the medical record showed that the patient had been in an auto accident. In another, the diagnosis was "palpitations"--irregular heartbeat--but the medical record listed chest pain among the patient's symptoms. In a third case, the claim form cited gout and hypertension, but the medical record showed the patient arrived by ambulance "in severe pain" and unable to walk.
As an outgrowth of the study, the agency this month began a review of emergency room claim denials by Mid Atlantic Medical Services.
In a statement, MAMSI, as it is known, said it "will continue to work closely with our participating facilities and physicians to assure" that claims are paid "quickly and fairly."