Tennessee Medicaid has had a waiver for years so that it could implement TNCARE, which was supposed to be a managed care approach to serving that population. TNCARE in the MCO format failed but the state has kept the structure in place. Now they have fiscal intermediaries who manage the reimbursements. 2 or 3 years ago they decided to limit the number of organization operating to just 2 in each of the grand divisions ( EAST,Central West TN). Once that occurred the organization then negotiated their fees and payments with the various providers. Hospital had the best position from which to negotiate and some were able to get a deal that was satisfactory. THe docs however had no strength and were basically at th emercy of the MCO. One of the MCO decided to pay only standard Medicaid rates.period! take it or leave it. The other wasmore amenable to negotiate with providers. I predict it is only a matter of time before the second more benevolant ( how ironic to use that word when even that org fees are substantially discounted to the private market) clamps down. Both of these organizations have shut down their reimbursements for ESI 4 &5 patients, saying these cases could have been seen in an office or free standing urgent care center. So for those patients that presented to the ED for care who were assigned ESI 4 or 5 , or whoose final diagnosis did not support an ED visit level of service, the MCO refused to pay. The best compromise I saw implemented was for the hospital to reconfigure the ED. Now there is an "urgent Care Center in the building ( actually in the ED itself) where patients who are triaged to the low acuity ESI levels are registered as if they went to a free standing UCC. I think they ( the MCO's) are making exceptions for kids< 2, but that will probably end soon. Because these patients are now registered differently, the place of service is now considered to be an urgent care center ( POS 23 instead of 20, ), so the E&M codes have to be from the 9920X- new patients and 9921X - established patients, series, since the 9928X series is restricted to ED use only. What that means is lower reimbursement because the RVUs for these codes is lower than the RVUs for the 9928X series. PLus now you have to remember to assign the patient to a code for established patient ( 9921X) if they had been seen in the clinic or by oe of the providers in the same group ( tax ID # used for billing), in the past 3 years. Once again patients who return ( frequent flyers) are billed using the established patient codes, which pay even less than the codes for a new patient) Still this approach is better than no pay at all..... Good luck!
Martin Herman, M.D.
Pediatric Emergency Medicine
Sacred Heart Children's Hospital
FSU @ Sacred Heart, Division of Pediatrics
5153 N. 9th Ave, 6th Floor Nemours Bldg
Pensacola, FL 32504
Ph: 850 416 7658
Fx: 850 416 7677
Email: [log in to unmask]
This email message and any accompanying data or files is confidential and may contain privileged information intended only for the named recipient(s). If you are not the intended recipient(s), you are hereby notified that the dissemination, distribution, and or copying of this message is strictly prohibited. If you receive this message in error, or are not the named recipient(s), please notify the sender at the email address above, delete this email from your computer, and destroy any copies in any form immediately. Receipt by anyone other than the named recipient(s) is not a waiver of any attorney-client, work product, or other applicable privilege.
> Date: Mon, 7 Nov 2011 03:10:29 -0600
> From: [log in to unmask]
> Subject: Re: Appointments in the ED
> To: [log in to unmask]
> Out hospital system has just announced that this service will be offered.
> In addition to the concerns expressed by Ernie, I have these additional
> 1) Approximately 55% of our patients are ESI Level 4 and 5. This means that
> if we could figure out a way to implement this, we would have to make
> available "appointments" to more than 25,000 patient visits/year.
> 2) Our population is approximately 70% Medicaid/Medicaid HMO. I am
> concerned that "scheduling appointments" will give the states just the
> excuse they need to decrease reimbursements to Hospitals for ED visits. In
> other words, why should insurance companies pay ED fees for non-emergent
> patients who have "scheduled" appointments?
> I would appreciate hearing your thoughts regarding the scheduling
> "appointments" for pediatric patients in Emergency Departments.
> Bob Flood
> Division Director, Cardinal Glennon Children's Medical Center
> St. Louis, MO
> On Tue, Sep 20, 2011 at 7:46 AM, Ernest Bertha <[log in to unmask]>wrote:
> > Just a thought as I am reviewing some CME.... If patients make an
> > appointment in the ED, is the hospital and the ED doc still responsible
> > under EMTALA? Obviously, if it is an appointment, no emergency medical
> > condition exists and therefore a MSE isn't required. Just wondering how
> > this might/will affect this type of care in the ED?
> > Ernie
> > Ernest G. Bertha, MD, MBA, CPE, FAAP
> > Chief Medical Officer, Pediatric Services
> > Sheridan Healthcare Services, Inc.
> > 1613 North Harrison Parkway
> > Suite 200, SH-10
> > Sunrise, Florida 33323
> > 954-838-2746 (Direct & Voice Mail)
> > 954-858-0100 (FAX)
> > [log in to unmask]<mailto:[log in to unmask]>
> > **Confidentiality Notice**
> > The information contained in this transmission contains confidential
> > information.
> > The information is the property of the sender and intended only for use by
> > the
> > individual or entity named above. The recipient of this information is
> > prohibited
> > from disclosing the contents of the information to another party.
> > If you are neither the intended recipient or the employee or agent
> > responsible for
> > delivery to the intended recipient, you are hereby notified that
> > disclosure of
> > contents in any manner is strictly prohibited. If you have received this
> > information
> > in error, please notify the sender immediately and arrange for the return
> > or
> > destruction of these documents.
> > For more information, send mail to [log in to unmask] with the
> > message: info PED-EM-L
> > The URL for the PED-EM-L Web Page is:
> > http://listserv.brown.edu/ped-em-l.html
> For more information, send mail to [log in to unmask] with the message: info PED-EM-L
> The URL for the PED-EM-L Web Page is:
For more information, send mail to [log in to unmask] with the message: info PED-EM-L
The URL for the PED-EM-L Web Page is: