RP Sanjiv Goenka Group

Part 2: Silent Denials…What you don’t know hurts the patient experience and your bottom line

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Testing your patient transfer policy… the next 3 of 9 critical questions and answers.

Welcome back for the second installment of this series on silent denials and testing your patient transfer policy. For those that missed the first part or need a refresher, you can find it here.

A quick refresh of context, our story began with a transfer from a neighboring hospital. On the surface, the transfer seemed appropriate to accept…until it wasn’t. This seemingly simple transfer turned into a series of denied claims in excess of $500,000.

So, while it may seem obvious, having a transfer policy doesn’t equal protection from the scenario you just read. When was the last time you reviewed your transfer policy? If you don’t know, don’t wait until the next transfer happens. Prevent this silent denial before it slips in through the back door of your hospital.

Let’s pull out (and dust it off if it’s been more than a year) your transfer policy. Here are the next 3 questions (and answers) to use in testing it:

1) Who is responsible for the patient during the transfer?

Under EMTALA, patient care during transport is the responsibility of the transferring physician/ hospital, until the patient arrives at the receiving facility. The transferring physician is also responsible for the order to transfer and for the treatment orders to be followed during the transport. This may conflict with State statutes, which in some instances, allow only authorized medical direction physicians to give orders to EMS personnel. EMTALA does not reference the transport service and its medical director, leaving ultimate medical responsibility and its transition during transport open for interpretation.

2) If the patient arrives into the ED is the payer required to pay for the entire visit?

Section 10101 of the Patient Protection and Affordable Care Act added numerous new patient protections to the Public Health Service Act (“PHS Act”), including Section 2719A which, requires group health plans that cover emergency services to provide such coverage without the need for prior authorization, regardless of the participating status of the provider, and at the in-network cost-sharing level.

In order to implement Section 2719A of the PHS Act, the Secretaries of the Departments of Health and Human Services, Labor, and the Treasury issued regulations that require the patient’s group health plan to reimburse out-of-network emergency service by paying “the greatest of three possible amounts – (1) the amount negotiated with in-network Providers for the emergency service furnished; (2) the amount for the emergency service calculated using the same method the plan generally uses to determine payments for out-of-network services (such as the usual, customary, and reasonable charges); or (3) the amount that would be paid under Medicare for the emergency service.”

Often patients and some Providers will confuse this rule and assume that if a patient arrives at an out-of-network (OON) hospital with an emergency condition, then the entire stay is covered. This is simply not the case. Payers will pay for the emergency portion of the visit until the patient is stabilized – assuming, of course, they agree there was an emergency in the first place. Once the patient is stabilized at that accepting facility, then an OON patient should be transferred to an in-network facility.

In terms of volume of denials, Providers most often see this when a patient is stabilized from a true emergency by the physician orders diagnostic tests like CT, MRI or lab tests to complete the diagnosis.  Payers consider this treatment “not-stabilization” and will deny the ancillary tests. Physicians often consider this to be an integral part of “treating” the patient and hence you have a conundrum. Focusing on this issue alone will often save millions of dollars in denials at the facility.

In terms of the greatest dollars of denials the patient that is admitted after transfer stabilization has the greatest impact. In some cases, the Payers will actually take advantage of this confusion to their bottom line benefit. If a patient is admitted OON and then stabilized, depending on the benefits of the group plan, the facility may receive no payment for services. When the facility attempts to transfer the patient, the Payer won’t authorize the transfer and without the authorization, other facilities may not accept the patient. The state and federal law forbid a facility from discharging the patient until there is a safe plan for continued care after they leave a hospital. For the facility, this essentially means that they will have to treat the patient through their full illness even though they will not be paid.

3) When should a facility say no to a proposed transfer?  Is an always “Yes” policy the best policy?

Often the question is: who makes the assessment to determine that a patient is stable (and able to be transferred) or unstable? Decisions may differ depending on the level of the practitioner, or between practitioners of the same level, or between the responsible practitioner at the transferring facility and the transfer team or its medical director.

Each facility should have a clear policy on who can accept/reject transfers on behalf of the hospital. There must be clear written procedures to follow if staff can’t reach an on-call physician or physician advisor on-call and an escalation process, as needed when the standard process breaks down for any reason. It is important that the facility educate the medical staff and all those involved in accepting or rejecting transfers on behalf of the hospital particularly as it relates to their responsibilities and EMTALA compliance.   The compliance officer should provide for continual education on a regular basis and modify the processes, as needed, based on CMS, OIG and/or federal court guidance as available. Internal audit or compliance should also monitor the hospital’s transfer acceptance and rejection activities to ensure compliance with the policy.

An informal policy to just say YES to all transfers will likely result in significant denials and unpaid patients. On the other hand, applying a very stringent policy and only accepting emergency transfers well reduce the facility’s ability to serve the community and surrounding area and could leave empty beds unfilled. Creating a transfer team with well-defined policies and a patient transfer process can allow facilities to navigate the various regulations, rules and idiosyncrasies to ensure compliance while maximizing revenue.

Ok, that’s a wrap for today’s post. Stay tuned for the third and final installment of this series covering the last three questions and answers of 9 in testing your patient transfer policy:

  • What is the role of the patient and/or patient’s family in a transfer?
  • Do transfers within the same system involve less risk?
  • What are the key components of a good transfer policy?

Like this blog? Click here to read: Part 3: Silent Denials…What You Don’t Know Hurts The Patient Experience And Your Bottom Line

Disclaimer: This document is a summary perspective of the guest author. It does not represent a formal legal interpretation by the author or Firstsource.

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