Question Regarding Admission from Emergency Department?

[prominence]

This is a general question as the culture at a VA or military hospital is different than at a civilian hospital:

If a patient presents to an emergency department at a civilian facility, endorses depression with passive suicidal ideations and is requesting to be psychiatrically hospitalized on a voluntary basis, will insurance companies generally provide authorization for such admissions?

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[ridethecliche]

Depends on how you swing it imho.

If they have a history of suicide attempts and/or have history of inpatient hospitalizations, you can talk about risk stratification and argue that they're in danger of decompensating further. If the passive SI is coupled with decrease in ADL completion etc then you can argue that as well. Are they having med side effects? Do they have access to a large quantity of potentially lethal rx meds? How are the social stressors anything big happen recently? Job loss/family death/etc?

A lot of the time, I think it comes down to documentation.

Generally though, this would be a partial referral. I've seen some places admit a patient like this for a couple of days till they can connect with the outpatient team, esp if weekend or such. It would likely be a soft admission with some eyerolls for folks having to discharge paperwork within a day or so of the patient getting in.

 

[Stagg737]

Completely depends on the insurance. I've seen some give coverage when admission was completely unnecessary. I've also seen plans where mental health wasn't covered at all.

Generally speaking though, it just depends on risk like beeker said. If you can justify that not admitting creates a direct risk to the patient's life it'll probably be covered. If this is the same passive SI that has been chronically documented without attempts, it might get rejected. Eithere way, you're not really going to know if insurance is going to cover this or not when you're deciding to admit unless the insurance just doesn't cover MH at all, so this shouldn't really be part of the clinical decision making.

 

[comp1]

In my experience, the culture is different at the VA and DoD hospitals. You admit because the patient could benefit from it and isn't likely to be harmed by it, ie re-enforcing maladaptive coping skills. There are other considerations as described above elsewhere. Obviously partials should still be considered first line in these situations outside exacerbating circumstances, even at the VA or DoD.

 

[Sushirolls]

The admission is appropriate if you clinically say it is. I have a patient right now, with no SI, or passive SI, but is barely functioning, and not pursuing any therapy, IOP, PHP. Speaks of hopelessness, struggles with work, and isolation, etc.

This person doesn't fit involuntary criteria, but could clinically benefit from voluntary hospitalization due to low function and daily impairment. Patient won't go...

As far as coverage? Some insurance simply won't pay. Some will pay. Some will allow admission, for 1-2 days, then say won't pay. Just depends.

The other issue, is if such patients go to ED with an attached psych unit, some ED docs will just discharge because no SI... despite "my psychiatrist told me to come." And they won't attempt to call the psychiatrist either. Or if there are no open beds on the unit, they will discharge from ED, also.

 

[clozareal]

It makes me sad to see these discussions focused on how insurance companies influence these clinical decisions rather than what would be the best for patients.

 

[mistafab]

Insurance companies don't need to "authorize" an admission. I think you may be referring to if they will end up actually paying for it or not on the back end.

If the patient shows up to the ED, it is my judgement that determines if they are admitted or not (and patient risk/voluntary status) that makes the final determination. My main concern is "would admission be helpful?" and "are they dangerous / how dangerous are they?" I do not consider insurance on the front end when determining admission. I document my judgement and move on.

 

[alina_s]

Insurance companies don't need to "authorize" an admission. I think you may be referring to if they will end up actually paying for it or not on the back end.

If the patient shows up to the ED, it is my judgement that determines if they are admitted or not (and patient risk/voluntary status) that makes the final determination. My main concern is "would admission be helpful?" and "are they dangerous / how dangerous are they?" I do not consider insurance on the front end when determining admission. I document my judgement and move on.

In all 3 of my training programs, insurance authorization for admission was absolutely our problem, and particularly difficult if we had to deal with Medicaid. I do recall once when I was approved to admit a kid who’d been declined coverage, and that was after hours of being up in the middle of the night waiting for the Medicaid support person to call back and then appealing to their psychiatrist. No, insurance isn’t clinical, but it can be your problem.

 

[Celexa]

In all 3 of my training programs, insurance authorization for admission was absolutely our problem, and particularly difficult if we had to deal with Medicaid. I do recall once when I was approved to admit a kid who’d been declined coverage, and that was after hours of being up in the middle of the night waiting for the Medicaid support person to call back and then appealing to their psychiatrist. No, insurance isn’t clinical, but it can be your problem.

You're both right. It can be a logistical nightmare, but that shouldn't be taken into account at the moment of your initial clincial decision. If you don't write patients for admission that otherwise meet criteria solely bc you know the insurance company won't want to pay, all you are doing is letting yourself be a liability meat shield for the moral crimes of insurance companies.

You assess the patient in the moment, and if they end up having to wait around while insurance plays games that sucks, and certainly that might be enough time for the pt to merit re-assessment and no longer require inpatient level care. That's fine. But don't do the insurance companies dirty work for them. That's part of why they get away with this ****.

 

[calvnandhobbs68]

In all 3 of my training programs, insurance authorization for admission was absolutely our problem, and particularly difficult if we had to deal with Medicaid. I do recall once when I was approved to admit a kid who’d been declined coverage, and that was after hours of being up in the middle of the night waiting for the Medicaid support person to call back and then appealing to their psychiatrist. No, insurance isn’t clinical, but it can be your problem.

That’s kind of weird though that it was your problem at all. That’s a social work kind of thing anywhere I’ve been. If there’s an appeal for coverage for admission or something it would then typically end up on the back end after they’ve been admitted with the inpatient team doing the appeal.

 

[alina_s]

That’s kind of weird though that it was your problem at all. That’s a social work kind of thing anywhere I’ve been. If there’s an appeal for coverage for admission or something it would then typically end up on the back end after they’ve been admitted with the inpatient team doing the appeal.

There was no social worker on at night in any of the ED’s where I trained. Or the psych ED where I worked as an attending. At least in the full psych ED, patients could be passed onto the morning shift if they needed to be admitted and I’d been unable to get them “approved” by insurance.

 

[michaelrack]

There was no social worker on at night in any of the ED’s where I trained. Or the psych ED where I worked as an attending. At least in the full psych ED, patients could be passed onto the morning shift if they needed to be admitted and I’d been unable to get them “approved” by insurance.

How is this not a violation of EMTALA (except in cases of elective detox admissions)?

 

[calvnandhobbs68]

There was no social worker on at night in any of the ED’s where I trained. Or the psych ED where I worked as an attending. At least in the full psych ED, patients could be passed onto the morning shift if they needed to be admitted and I’d been unable to get them “approved” by insurance.

Yeah that's super unfortunate I guess and just sounds like a major systems problem at those places. The ER docs aren't waiting for insurance "approval" to admit people or not. They either have someone else doing it for them or they just don't care.

 

[alina_s]

You’re right, Michaelrack, I’m blurring together 3 awful processes that stood between clinical decision making and actually admitting someone. I think the more common reasons patients stayed in the ED were a) waiting for the assessors who got to decide whether someone could be involuntarily admitted, and were also the gatekeepers for lower-level crisis beds and b) no beds anywhere. But we did have to get insurance/Medicaid approval, unlike any other admitting specialty, and I remember getting hospital approval to admit against Medicaid’s decision only once. I have no idea why that process was legal, but some of the parts of it were mandated by Medicaid, not the hospitals.