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Case Management denying admission

Discussion in 'Emergency Medicine' started by EM Junkie, 04.21.12.

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  1. EM Junkie

    EM Junkie SDN Donor

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    This question is directed more towards those in post-residency life.

    I'm the ED Medical Director of a busy suburban ED (50K visits). Our hospital has hired a new Director of Case Management who has an entirely new approach to ED case management.

    While the old Case Manager would sit side by side with us in the ED, and request better documentation to justify an admission or admission vs. obs decision, the new lady has blocked several admissions because they "don't meet criteria".

    Case 1 was a lady with new, severe hemorrhoids that couldn't poop, obs for pain control and surgery c/s.

    Case 2 was a schizophrenic off meds, on her period, with an asymptomatic anemia (Hgb 7.5). Psych facility wouldn't take her without a transfusion, so obs for transfusion and psych dispo.

    Case 3 was similar to 2 (psych vs organic, obs for drugs to wear off and psych eval)

    All three stayed in the ED for hours (up to 24), and 1 and 2 were eventually admitted after the Case Manager's meddling plans fell through.

    I have a meeting with her and my ED leadership team next week. Are there any laws/rules which I could use to stop this practice? I'm all for a collegial discussion and adding documentation to support an admission or level of care decision, but as you can imagine blocking my docs' admissions doesn't go over very well with me or the nurses.
     
  2. curious1x

    curious1x

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    You and your docs are MDs here.
    If it does not meet some criteria, let her get creative and find something to meet the requirement.
    On rare occasions if I run into this, I just politely ask them if they would like to discharge the pt, and somehow the pt gets an obs bed!
     
  3. EctopicFetus

    EctopicFetus Keeping it funky enough

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    Ours dont block admits but rather change them to/from obs status. Anemia requiring a blood transfusion needs a workup. IMO you can find a reason to admit ANYONE. have a complaint? I can find a way to admit it. That being said im more a wall than a revolving door.

    I imagine your meeting will be fruitful. Keep in mind the hospital wants you to move patients through the system so they should be in your favor. Your new hire might have done things differently from where they came.
     
  4. Birdstrike

    Birdstrike

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    .
     
    Last edited: 08.05.12
  5. EctopicFetus

    EctopicFetus Keeping it funky enough

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    After ruminating on this last night. It is one of the most frustrating parts of my job. Not exactly this nor the Case manager asking if the patient should be obs and not inpt or remote tele vs tele.. but more the larger issue. Non physicians making me do things I dont want to.

    The nursing home who wont accept the patient until x, the psych facility who wont take the patient until the BAL is under 200. The group home who wants something stupid done. Being told what to do my non medical types drives me nuts. I have learned not to fight it anymore cause it frustrates me so much.
     
  6. TysonCook

    TysonCook Senior Member

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    ...only run into it once or twice, and my response was the same as above "okay, you discharge them and be sure to document why.."
     
  7. southerndoc

    southerndoc life is good Moderator Emeritus Lifetime Donor

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    We have a case worker from 8a-midnight that reviews all admissions and determines if they should be obs or inpatient. She also advises us of any readmissions, and is great at arranging hospice, walkers, wheelchairs, home O2, etc.
     
  8. Arcan57

    Arcan57 Junior Member

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    Sounds great, it also would lead you to be fired from pretty much any community shop in the country.
     
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  9. emedpa

    emedpa GlobalDoc

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    our case managers go home at 5. If I can swing it I don't call for the admission until 5:15 if I know they would try to be obstructive...same deal with the surgeon who accepts no one. wait until shift change when a reasonable surgeon takes the pager...
     
  10. Birdstrike

    Birdstrike

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    .
     
    Last edited: 08.05.12
  11. dotcb

    dotcb ---------

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    These administrators rarely have any power or teeth.
     
  12. fergustsi

    fergustsi

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    Im an intern so take this fwiw, but i was told by case management one time that if you just document unsafe to discharge, this gets them an obs bed.
    case management at our program is great, always there 24 hours a day and always willing to dig through that book to find a reason to admit if none is clear.
     
  13. logos

    logos 100% Organic

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    Our case management usually will help us meet criteria. If they need to stay and I know its a weak case I diagnose as many things as I can, intractable pain, anemia, hypokalemia (even if incredibly mild...3.5 etc), hypomagnesemia, dehydration, etc. Also send a urine and get a CXR as there is a reasonable probability that one or the other will be (falsely) positive. Also if not dangerous put them on IVF at a set rate, make NPO (can't go home NPO, need iv hydration) get peak flows in asthma and COPD (the patients never do it right so the numbers are always abysmal). An extra dose of zofran makes that nausea "intractable" even if it wasn't needed.

    Ultimately we have a physicians over-ride if none of that works which may be a solution to the OPs problem but it means that the hospital is going to eat at least some of the stay.

    Ultimately you have to do what is best for the patient and if that means playing the system a little bit then so be it.
     
  14. The White Coat Investor

    The White Coat Investor AKA ActiveDutyMD Partner Organization

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    Our case manager kept trying to get me to admit people who didn't need to be admitted.

    "But he meets criteria doctor!"

    "I'm sure he does. But I'd still be too embarrassed to call a hospitalist to admit him for that, and the patient doesn't want to come in anyway."
     
  15. BADMD

    BADMD

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    Some of that sounds potentially fraudulent.
     
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  16. dsh1234

    dsh1234

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    Ordering useless tests like CXR's and urines when you have zero pre-test probability and hoping for a false positive to get them admitted..... Wow. I know what you're trying to say, sometimes you have to work the system, but that's not something I'd ever do or recommend doing. The inpatient doc is gonna have to be obligated on some of those cases to put them on a course of abx for that super weak atelectasis vs PNA on CXR cuz you went looking there when you had no business to.... and that could lead to all kinds of preventable complications.

    I am no means one of those doctors that sits on his moralistic high horse, citing hippocratic oaths and waxing poetic on the symbolism of the white coat and whatnot. As an internist, this just gets me angry. You really have no business doing that crap. If that patient can't meet inpatient criteria and you can't even spin it without ordering unnecessary tests, then maybe the patient truly should be going home and you're actually the idiot.
     
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  17. dsh1234

    dsh1234

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    I see this guy deleted his original post. Note to all trainees and residents out there: FFS do not do what the the ED doc is suggesting in the post this guy I quoted above is referring to. I actually bet he's never written anything like that in his entire life in a patient's chart, and he's just trying to act like a big shot on the Internet. I guarantee you that if you ever get into a disagreement with another MD, or nurse/social worker/PA and you start littering a patient's chart with amateur wannabe legalese, acronyms of medical acts, legal threats, and of course to top it all off - decide to include every single one of your superior's names as the targets of them, then yes, you will be finding yourself without a job pretty quickly.

    Arrogance overcomes a lot of doctors and you have to be mindful of that. Just because you think you are trying to do things in the name of patient care, doesn't mean you can do whatever you want and be as confrontational as you want. I've seen more than my share of academic physicians with superb research resumes get let go in less than a year because they would get into a fight with the nurses every single week. And, whatever you do, do not turn a patient's EMR record into a passive-aggressive battlefield of words like this idiot is suggesting you do. Nowadays more and more patients are enrolling in programs where they can access all their charts and labs from home computer login. Having the patient see that crap go on with his treatment team behind the scenes is just one of the hundred of different reasons why you don't want to leave that garbage in the EMR.
     
    Last edited: 08.05.15
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  18. WilcoWorld

    WilcoWorld Senior Member

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    Agreed. Document what your concerns were, that you communicated these concerns to the admitting team, and that, for reasons XYZ the admitting team did not feel that admission was warranted. If their rationale is ridiculous, point that out to them and figure out a way to get the patient admitted. If their rationale makes sense, putting it in the chart will protect you both.

    Lambasting your consultant in the chart, and then bending to what your consultant wants, will only make you both look stupid and will show that you should have known better. Having doctors fight in the medical record has got to be like blood in the water for the sharks.
     
  19. Birdstrike

    Birdstrike

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    You dug up a 3-yr-old post, and completely missed the point, while mixing in some name calling. (I deleted all my posts at one point, so the fact that I deleted that one had nothing to do with post content. Anyone who wants can click on Arcan57's post to see my original). The point was, that a physician should not let a nurse who does not practice medicine, bully him into discharging a patient that needs to be admitted, for financial gain and at the expense of the patient and physician liability.

    My post referred to what a physician might need to say to such a nurse "case manager," to ultimately advocate for a patient. Rarely, if ever, would anything come to such a severe impasse actually requiring any of this to be documented in a patient chart. Because what the OP described, was a nurse who was essentially practicing medicine by blocking a physician order and medical decision making to prevent a needed admission for a sick person. Note that such a nurse accepts no liability by bullying a physician into discharging a patient because he/she is refusing to do their job, which is to think creatively with the doctor to help augment documentation, to help get a patient's admission payed for, not blocked. And they know this. They know they're not actually going to block you from admitting a patient that needs to be admitted if the only reason you're discharging them is their order, and you're willing to say so.

    So you do have to assert yourself. Yes, admittedly it needs to be done in a politically correct way for self-preservation in today's day and age, but you must be able to do your job, do it properly, safely and in a way that allows you to avoid excessive liability. There is certainly an art to taking a stand effectively, and without being disrespectful, or "disruptive" in a way that would give anyone enough traction to get you fired, like you might if one unleashed the name calling you have in your posts, such as those below. I think most of us have the ability to be much more tactful that that.

    That being said, if physicans are unable to master the art of pushback in a way that does not put their job at risk, and want to roll over and concede their decision making to a nurse who will conveniently offer no liability protection for the consequences of the decisions they concede to him/her, and let nurses bully them into discharging patients their years of training tell them need admission, so be it. We're all big boys and girls now, and we have to live with the consequences of our clinical decisions, including those we allow non-physicians to make for us.

    In the meantime, I'd like to take a moment to appreciate the ad homenim attacks and name calling from the illustrious 4-post history of @dsh1234 who popped up under a new screen name 5 hours ago:

     
    Last edited: 08.05.15
  20. msgsk

    msgsk

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    This is better than anything on daytime TV!
     
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  21. Birdstrike

    Birdstrike

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    The OP referred to a "Case Manager" telling the doctors, including the ED director himself, to send home patients they determined needed admission, not an admitting physician consultant sending them home. Those are two entirely different scenarios.

    Typically a case manager is a non-treating, non-physician, chart reviewer that bears no responsibility for patient care or outcomes. I can't believe you'd be so quick to roll over to give one veto power over your medical decisions, but hey...whatever. Not my circus, not my monkey. It's all good.
     
    Last edited: 08.05.15
  22. Birdstrike

    Birdstrike

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    Yes, we're definitely better than any "Real Housewives" or Jenner-dashians, aren't we?
     
  23. WilcoWorld

    WilcoWorld Senior Member

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    I should have been more clear that I was solely agreeing with the assertion that the medical record is a poor venue for contention between docs.

    Admittedly, I was being lazy and didn't bother to go back and reread the posts newusername1234 was referencing. If s/he's saying that playing the game in order to take care of the patients (in spite of the case managers' obstructionism) is fraudulent - I strongly disagree.
     
  24. EM Junkie

    EM Junkie SDN Donor

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    Wow, my post has become a legend! For the record, we were able to work well with the new Director of Case Management, they placed a Case Manager in the ED during busy times of the day, and no admissions have ever been blocked by them since.
     
    Last edited: 08.06.15
  25. Doctor4Life1769

    Doctor4Life1769 **tr0llin, ridin dirty**

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    Why does an asymptomatic anemic patient with presumably no hx of CAD/CHF requiring a blood transfusion for Hb 7.5 if it's completely stable without evidence of bleed?
     
  26. Arcan57

    Arcan57 Junior Member

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    Psych facilities policies and evidence based criteria are not necessarily orthogonal to each other but the psych hospital doesn't have to take a patient just because we say they need stabilization.
     
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  27. Birdstrike

    Birdstrike

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    I believe it was because the OP was stuck in a quandary. I've been there countless times. The patient did have evidence of ongoing bleeding (menstral period). Though it may be physiologic bleeding, and maybe hemodynamically asymptomatic, the context (according to his OP) is that the patient was actively psychotic off meds, and therefore not reliable for a dispo such as "follow up with Gyn in 24 hr to assess for possible development of symptoms and repeat hemoglobin."

    An actively psychotic patient, that is off meds, not thinking even remotely clearly, already proven to be non-compliant as such, with labs abnormal enough (hgb 7) to make most sensible practitioners nervous, and with obvious reason to the think the problem will continue to get worse (losing more blood) with close follow up not likely, is just about the worst possible candidate for treatment in the outpatient setting imaginable. It's an absolute setup for disaster and you'd be right to push for admission in some form, 100 out of 100 times.

    Also, note he tried to get the patient to psych, then already got blocked there due to the hemoglobin. Then he gets blocked by his own facility, because of some "case manager" pushing for inappropriate (but cheaper) care, who after a "chart review" tries to bully him into pushing a patient who is unstable on multiple fronts, out the door to bleed their hemoglobin down under 7, during an episode of altered mental status. Then he posts the case on a medical discussion board and gets an angry retort (albeit 3 years later) with name calling from an internist that "hates the ED" who thinks no one should ever be admitted and EM physicians are "idiots."

    This is an example of a helpless, defenseless patient, vulnerable to be harmed and spit out by the system, that absolutely needs a doctor who cares, to advocate for them. Otherwise, they get battered around like a pinball and then spit out to the street to bleed their hemoglobin down from 7 to 6 to 5 while actively hallucinating, and no capacity to advocate for their own care, so that the "case manager" can get some brownie points with her administrative supervisor by saving the hospital CEO some money and increasing his quarterly bonus, so the psych facility can have a cozier shift, and so a disgruntled misanthropic hospitalist can avoid a patient he's lost all compassion for and avoid a department he hates.

    This is a patient you can actually help, if you have the heart to see through the frustrating mess of insanity circling around what should be simple decision making. This is actually a very god learning case for how an Emergency Medicine can be made very difficult due to countless factors that have nothing to do with "emergencies" or "medicine."

    I can just here the plaintiff's attorney asking during the deposition, "Now that we know this patient went home and bled out for several days, too psychotic to coherently take care of herself, and now that we have the autopsy results including a hemoglobin of 4, doctor, why again did you somehow think it was proper to discharge an anemic, psychotic, altered and bleeding patient from the hospital?"

    Dr XYZ, "Uh...uh...because...duh... the case manager told me I should......and...uh, duh..." head scratch," and...the hospitalist was grumpy...and has the habit of...uh...duh..." glances over to defense attorney, "...calls me mean names...uh...when he's had more admission than he likes in a shift, and uh...I was afraid I might lose my job, so...."

    Then says the plaintiff's attorney, with an anticipatory and excited giggle, "So, you didn't do it because it was standard of care, but because of all of those..." with outrageously smug and mocking airquotes, "reasons?"
     
    Last edited: 08.05.15
  28. Doctor4Life1769

    Doctor4Life1769 **tr0llin, ridin dirty**

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    I get it, thanks for the post.
     
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  29. The White Coat Investor

    The White Coat Investor AKA ActiveDutyMD Partner Organization

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    Totally inappropriate obviously. Makes me thankful for the one we had for a while. In the end, I could always do whatever I want. She actually wanted me to admit a lot of people that were fine to go home!

    Edit: Ha ha, didn't realize it wasn't an old thread. I already responded to this one!
     
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  30. d2305

    d2305

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    He went to the trouble of joining the forum just to call the esteemed Dr Bird an idiot. Sounds like an unhappy patient.
     
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  31. Dr.McNinja

    Dr.McNinja Nobel War Prize Winner

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    They're bound by EMTALA just like any other hospital. If they don't want the patient, there needs to be some sort of mobile crisis unit evaluation that states against hospitalization.
    http://www.emtala.com/ig.pdf
    As an FYI, it's a huge violation for them to require medically unnecessary tests simply to "medically screen" a patient, but as a group EPs have been unwilling to file Qui Tam cases against them. Such as life.
     
  32. Arcan57

    Arcan57 Junior Member

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    They are only bound by EMTALA if they take federal funds. The majority only accept private insurance and are free to come up with whatever ridiculous rules they want.
     
  33. GeneralVeers

    GeneralVeers Globus Hystericus

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    I generally like our case manager. I'll get her to go into the room and talk to the families of demented old people, or hospice people. Many times family is pushing for admission to the hospital on a patient who is already in a nursing home/hospice with no acute medical issues. The case manager can usually explain to them how medicare won't pay for the admission and they will be stuck with the bill. Usually after her talk the family agrees to let their demented loved-one go back to their SNF or hospice.

    Conversely when I have a weak admit who I think should come in, I have our case manager evaluate. They usually agree that the only way to get SNF placement/transfer is to admit the patient. Then when I call the hospitalists/internist with my weak/BS admission I can tell them: "Case management has already evaluated and determined that the only way to get outcome X is to admit". Rarely do I get much pushback at that point.
     
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  34. Dr.McNinja

    Dr.McNinja Nobel War Prize Winner

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    This is true. None of mine are private, the private ones closed down.
     
  35. emergentmd

    emergentmd

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    I haven't had a chance to look through all of the reply and I am a ED Med Dir at a 50K place too so prob all the same issues.

    My response to anyone who wants to block an admission (assuming that I feel there is no other choice. I am reasonable and will take in all info to decide) is this

    1. Hospitalist - If you do not think pt needs admission, then you are still consulted. Please come down, see the pt, take responsibility, and write a consult note. Then you can discharge them. This fixes it.
    2. Case worker (although i have never had an issue) - Pt needs admission, if you do not think pt needs admission, then please come down. Evaluate the pt, write a note, make sure the CEO/CMO is on board. Once you get everyone on board, my note will read that I believe pt needs admission and the case manager/administration refused admission. I would also make this clear to the family and pt. Trust me...... This will fix the issue Very fast.
    3. Hospitals not wanting to take transfer - On recorded line ....... "I believe this pt needs admission as our hospital does not have specialty to care for pt. I will document that your hospital has refused transfer for higher level of care. Can you please state that you are refusing transfer for higher level of care?" - Trust they will gladly take the pt.

    At the end of the day, if I discharge a pt against my better judgement, I want no responsibility in this matter. Pts will have bad outcomes, everyone would deny responsibility, you will be left holding a bag.

    Maybe I am lucky to work in a place where admission is fairly easy. Maybe by working here for 15 yrs I have alot of Street Creds. But getting pts admitted rarely results in any amount of my time. I spend about 10 secs on getting someone admitted. I text the hospitalist and usually the pts disappear. Sometimes I will get a call with questions but this is rare and lasts maybe 30 sec.

    I do remember when they changed admission criteria and I would hear from the hospitalist , "I can't admit for old and weak". My answer would be, "family wont take home, pt can't stand, what then should I do"? After awhile, this conversation endedn.




    I had a partner who wanted to admit a cardiac pt. Cardiologist refused and told him to send pt home. Guess what, pt died. Guess what, Cardiologist denied every refusing to care for pt. Guess who held the bag????
     
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  36. Birdstrike

    Birdstrike

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    Yes, yes, yes. I agree with all of this. It's true. You cannot let people play games with this stuff, especially when you and only you are held accountable for the outcome.
     
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  37. southerndoc

    southerndoc life is good Moderator Emeritus Lifetime Donor

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    Be careful. Play too much hardball and you might be out of a job.

    I've been on the receiving end of people who don't need to be transferred, and as soon as they get to my shop, I discharge them. It's a huge waste of the patient's time and their money to transfer them. Listen to the person on the other end of the transfer line. If they tell you that such a facial fracture is usually sent home and OMFS doesn't see them in the ED, then maybe you shouldn't transfer the patient and should discharge them with outpatient followup.
     
  38. emergentmd

    emergentmd

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    Man, What a beat down. I get why you did it but what a beat down.
     
  39. emergentmd

    emergentmd

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    One reason we can play hardball is my Job is secure. If they want to get rid of me (Doubt it as I have been on countless admin committees, know the CEO personally), so be it. I can find a job that would pay more tomorrow. I am reasonable but when I need to, yes i will play hardball. If I know a doc is a difficult admin, I fluff it up.

    We are a receiving hospital, I have had people come just to be transferred. But you have to remember that the EM docs are our colleagues, they may have terrible support, they may not feel comfortable discharge someone that I would discharge. But if they want to send someone, and I think they may be Discharged, I tell them, "I am happy to take them, can you just inform the family that we may discharge them with follow up."

    We all have been through residencies when admission and transfers was a PIA. I would not wish that on anymore. I am not by the pts bedside, who am I to deny a transfer? I can't complain about a hospitalist not admitting my pts but then deny another doc a transfer. Plus its usually EASY money.
     
  40. southerndoc

    southerndoc life is good Moderator Emeritus Lifetime Donor

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    How is it easy money when only one provider can bill an emergency fee in a 24-hour period?
     
  41. GeneralVeers

    GeneralVeers Globus Hystericus

    Joined:
    03.19.05
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    Las Vegas
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    Attending Physician
    Physician SDN 10+ Year Member
    Because at most shops if you are on RVU you get credit for that patient and you get paid for it even if the group as a whole doesn't.
     
  42. The White Coat Investor

    The White Coat Investor AKA ActiveDutyMD Partner Organization

    Joined:
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    Attending Physician
    Physician SDN Partner SDN 10+ Year Member
    You got a link to that rule? I assure you we bill emergency fees often for repeat visits in less than 24 hours. We also bill a fee for an ED to ED transfer. As far as I know, we're being paid for those visits.
     
  43. emergentmd

    emergentmd

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    SDN 7+ Year Member

    I have heard this EM charging rule but never verified it. But I bill and we are RVU based so no matter if pts pay or not it doesn't matter. It only matters how much RVU I accumulate. But really, even if i didn't get paid, I would do the same.
     
  44. southerndoc

    southerndoc life is good Moderator Emeritus Lifetime Donor

    Joined:
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    Physician SDN 10+ Year Member
    Sorry, I've never verified it (never had reason to). Just what our admins tell us.
     
  45. goodoldalky

    goodoldalky Member

    Joined:
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    Messages:
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    Attending Physician
    SDN 7+ Year Member
    My understanding is the rule on transfers is you can only be paid for one EM code unless the transfer is to a different hospital without a merged medical record system and both providers are in different group numbers. IE if your group covers two hospitals and you transfer from one to another you can only bill once. But if you transfer to me we can both bill.

    As far as the multiple visits on the same day, once again if this is within the same group the GENERAL rule is you bill once. See q4: https://www.oxhp.com/secure/policy/same_day_same_service_policy.pdf
    Exception being if you "include justification" you can bill a 99284-5 once maximum and 99283 or less subsequently. What that means by justification exactly is ill defined. Link: https://files.medi-cal.ca.gov/pubsdoco/publications/masters-mtp/part2/eval_m00o03.doc
     

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