HCFA agrees to rework E/M guidelines
Health Care Financing Administration also begins training surveyors on new administrative guidelines for EMTALA enforcement
Two recent developments concerning the Health Care Financing Administration (HCFA) presented hopeful news for emergency physicians. "For the first time in a long time, the news on the regulatory front has been good," says Charlotte Yeh, MD, FACEP, chief of emergency medicine at New England Medical Center in Boston. "Finally, we have a few positive things to report." Here is an update.
Revised EMTALA guidelines. ACEP participated in a three-day training course in March for HCFA surveyors on the newly revised administrative guidelines. The guidelines are scheduled to be published in approximately 60 days, and they will become effective 30 days thereafter. "The goal was to clarify the guidelines from the perspective of enforcers as opposed to providers, and help them understand the application and nuances of clinical practices," says Yeh, who attended the session.
At first, there was concern about having health care providers take part in the training session. "Some people thought it was very inappropriate that the EMTALA task force even existed. They felt that having AMA and ACEP involved was having the fox guard the hen house," says Larry Bedard, MD, FACEP, director of emergency services at Doctors Medical Center, San Pablo and Pinole Campuses (CA).
"The first day of the meeting, there was a lot of skepticism and outright hostility," he reports. "But, by the end, they got a much better appreciation of the dilemma that emergency physicians are in. They realized we are patient advocates and don't have any financial incentive for transferring patients."
Overall, the training session ended on a positive note. "It was a valuable exercise for both sides," notes Yeh. "We as emergency physicians left with a far better understanding of the problems and issues that the surveyors face. We recognize that there was a strong interest and dedication on their part to assure access. It was also healthy for surveyors to see emergency physicians who cared as much about access to emergency services as they did."
The revised guidelines are expected to result in EMTALA regulations being enforced more consistently and fairly. "But it's important to understand that while administrative guidelines give guidance to surveyors, they, in no way, shape, or form, replace the actual regulations," Yeh stresses.
The revised guidelines clarified the definitions of a medical screening examination, stabilization, and prior authorization. "Those are probably the most significant pieces and are helpful from the emergency physician's standpoint," says Yeh. "HCFA did accept the majority of the recommendations from the EMTALA task force. So, I think the overall message is, this is a positive step forward."
The concern that EMTALA is not enforced consistently nationwide rang true at the meeting. "A nurse reviewer from Wyoming said she never asks for peer review on any case involving medical judgment. Then somebody from another region got up and said they always asked for peer review in those cases," Bedard reports. "So, I think HCFA leaders who attended this meeting got a real appreciation for just how the law is being differently enforced depending on what region you are in."
In any case, there is clearly more work to be done. "It's clear that some major areas require more discussion, including on-call physicians, psychiatric patients, and inpatient admissions," notes Yeh. "Those are just a sampling of topic areas that will need to be looked at in the future."
The EMTALA task force, which has existed for two years, will continue. "I believe HCFA realizes there is still unfinished business, and recognizes the importance of keeping the task force together," says Bedard. "Hopefully, this isn't the final chapter of EMTALA."
In the distant future, the actual regulations may be revised, reports Yeh. "Since regulations interpret the statute, they have the same status as law, whereas administrative guidelines aren't legally binding," she explains. "So revised regulations would have a much greater impact."
Documentation guidelines. In early April, the AMA held a "fly-in" meeting where it was announced that the documentation guidelines for evaluation and management services would be indefinitely postponed.
Delayed once already, the guidelines were scheduled to go into effect on July 1, 1998. Because the medical community had protested that the guidelines were too complex and burdensome, HCFA decided to delay implementation pending a final revision. "Knowing how much controversy there was, and the intensity of the reaction, I would have expected it. I wasn't expecting it to be announced that day, but I was delighted," says Yeh.
Emergency medicine was the first specialty to raise concerns about the complexity of the guidelines, Yeh notes. "ACEP was the first specialty to attempt to work with AMA and HCFA, and not only raised concerns, but had some positive suggestions to offer," she adds.
The postponement is a clear victory, Yeh says. "We are pleased with the indefinite postponement," she says. "Many of our concerns are hopefully going to be addressed in some of the draft versions, thanks to active involvement of ACEP at both the national and regional level early on. At least in the initial versions, our versions are very favorably represented."
Although no timeline has been announced, it will likely be at least a year before revised guidelines are completed. "They are going to look at it again and come up with further recommendations this fall," says Yeh. "My personal feeling is, I wouldn't be looking for this anytime soon."
The fraud and abuse issue was also addressed. "It was announced that in order to be found for fraud, the standard has been raised to `knowingly,' as opposed to a simple billing error," says Yeh. "How much impact that will actually have on investigations remains to be seen, but it's good news."
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