All Indiana Medicaid Managed Care Entities (MCEs) who choose to use a list of diagnosis codes to determine whether to cover emergency department claims must use, at minimum, a standardized list compiled by the Indiana Office of Medicaid Policy and Planning (OMPP) beginning April 1, 2020.
The list, known as an autopay list, has more than 16,000 ICD-10 codes considered to be emergency conditions by OMPP. According to the new policy, MCEs must compare at least the first six diagnosis codes on a claim to the autopay list. If a diagnosis code on the claim appears on the autopay list, then the claim should be paid at the contracted rate for the CPT codes billed.
Prudent Layperson Review
A claim with no diagnosis codes on the list, but which the physician believes constitutes an emergency based on the patient’s conditions, can be appended on initial submission with medical records to implement a prudent layperson review. Claims reviewed and determined to be emergencies will then be paid at the contracted rate for the CPT codes billed. Otherwise, claims deemed non emergencies will be paid at a screening, or triage,” fee rate, typically around $16 or the equivalent of a level 1 ED visit.
Emergency physicians also can submit medical records and request a prudent layperson review within 120 days after a claim is paid at the screening fee rate if not done at the time the claim was initially submitted. MCEs must conduct the review within 30 days of receiving medical records and reprocess the claim for additional payment if the service is deemed an emergency.
Other Guidelines for Emergencies
In addition to the autopay list or a successful prudent layperson review, services also are considered emergencies—and claims paid according to the fee schedule—if a patient first calls the MCE’s 24-hour nurse line and is advised to report to the emergency department. As well, claims for patients admitted to observation from the ED must be paid by MCEs regardless of whether the ED visit itself was determined to be an emergency.
In some cases, MCEs may have more lenient requirements for paying emergency services, but according to the new policy, MCEs may not enact more stringent requirements.
Of the four current Indiana Medicaid MCEs, Anthem, CareSource, and MDwise [AUTOMATIC DOWNLOAD] currently use autopay lists for processing emergency department claims. Managed Health Services does not appear to have an autopay list in place but would also be subject to these new policies if they implement one.
A History of Lists
Lists of these kinds have been used for several years as a way for payers to quantify the prudent layperson guideline for determining emergencies.
According to state and federal law, an emergency medical condition is defined as “a medical condition manifesting itself by acute symptoms of sufficient severity (including severe pain) such that a prudent layperson, who possesses an average knowledge of health and medicine, could reasonably expect the absence of immediate medical attention to result in the following:
- Placing the health of the individual (or, with respect to a pregnant woman, the health of the woman or her unborn child) in serious jeopardy
- Serious impairment to bodily functions
- Serious dysfunction of any bodily organ or part
Physicians, however, have balked at using final diagnoses as a way to evaluate the prudent layperson standard. They insist that presenting symptoms offer a much more compelling picture of what patients are thinking when they present to the ER. And even then, both mild and severe conditions can share presenting symptoms.
“it is often impossible for emergency physicians, much less patients, to know based on a patient’s initial symptoms whether their condition will ultimately end up being emergent,” wrote Laura Wooster, MPH, and Leslie Patterson Moore, JD, for ACEP Now back in 2018 when the American College of Emergency Physicians (ACEP) joined the Medical Association of Georgia to file a lawsuit against Anthem’s BlueCross BlueShield of Georgia over a policy of retroactive denials of ED visits that the insurer deemed as “non-emergent.”
ACEP continues to fight against payer policies that deny coverage for members “who seek care for what it deems as non-emergent conditions at an out-of-network facility, as well as Medicaid managed care plans and state waiver applications that also erode the prudent layperson standard.”
For more information about Indiana Medicaid’s new Autopay List for MCEs, review IHCP Bulletin BT202009. Other resources highlighted in this article include:
- Anthem’s “ER Auto-Pay List process change”
- Anthem’s Current Autopay List
- CareSource’s Network Notification “Emergency Room Auto-Pay Reimbursement”
- MDwise’s Provider Manual: Hoosier Healthwise and Healthy Indiana Plan (HIP)
- MDwise’s Current Autopay List [AUTOMATIC DOWNLOAD]
- Indiana Health Coverage Programs Provider Reference Module: Emergency Services
- “ACEP Defending “Prudent Layperson” in Court” by Laura Wooster, MPH, and Leslie Patterson Moore, JD, on September 5, 2018 for ACEP Now
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