Payers should omit urgency as a factor in ED payments
Hospital emergency department (ED) personnel can’t seem to agree on what constitutes a legitimate need for urgent care in patients presenting with a wide range of medical problems.
So how can retrospective reviewers at most insurance companies make valid payment decisions on similar criteria, a recent study suggests.
The study, published in the November 1996 issue of the Annals of Emergency Medicine, indicates that disagreements are highly probable between physicians and claims reviewers regarding the medical necessity of urgent care in an ED.
The study recommends that payers base their decisions on standards that do not include whether they agree with physicians on the urgent nature of treatment. Urgency assessments, the study adds, is a poor indicator of medical necessity.
To reach their conclusions, researchers reviewed the records of 266 ED patients in an urban teaching facility. Using identical criteria for assessing urgency retrospectively, they found the proportion of encounters rated as urgent ranged from 11% to 63% among physicians and only 9% among ED nurses.
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