The Narrow Network Conundrum: Admit or Transfer and the No Surprises Act”Madisyn Schmitz, JD, MHSA, RHIA, CPC Richelle Marting, JD, MHSA, RHIA, CPC This article is written for educational purposes and is not intended to constitute legal advice. Issues surrounding admission and transfer involving the emergency department can be complex and your legal counsel should be consulted for your own organizational strategy. A growing trend in the industry is for health insurers to form narrow networks by contracting with a select few providers, which typically include less than one third of eligible providers in a given geographic location. The Government Affairs Committee recently discussed this trend and the implications of transferring patients from a facility outside of the plan’s narrow network to another location in the plan’s narrow network. After all, emergency departments have long been aware of such implications because of the risks of transferring patients due to EMTALA restrictions and concerns for patient dumping from lack of insurance or adequate insurance coverage. Picture this: a patient presents to the ED with chest pain, and initial workup reveals elevated troponin, and the working diagnosis is AMI. The Emergency Physician contacts the Hospitalist who agrees with the plan to admit the patient. Subsequently, an order is entered for inpatient status and the patient’s health plan is notified of the admission. The response is returned: denied. But, unlike many inpatient status denials tied to the health plan’s interpretation of the two-midnight rule or their own criteria (Review ACPA’s GAC Town Hall for strategies to manage plans’ use of the two-midnight rule), this denial is different. Inpatient status here was denied because your hospital isn’t in-network with the patient’s health plan. What next? Under the lens of EMTALA, a patient has presented to the emergency department requesting evaluation or treatment. The patient has presumably received a medical screening examination by a qualified professional who determined an emergency medical condition existed. Upon that determination, the hospital has an obligation to: provide stabilizing treatment regardless of the patient’s insurance status or ability to pay. The ability to transfer is only prompted by the initial hospital’s inability to treat the patient’s emergency medical condition. However, if the patient is stable, one hospital may transfer the patient to another facility. If an admission is denied by the health plan for being an out of network facility, the transfer from one hospital to another is being initiated while the patient is registered to the ED, and there is always uncertainty and risk when transferring from the emergency department. Even with the best documentation surrounding the patient’s stability, “stability” is subjective and if the receiving facility finds the patient unstable, the transferring facility risks an EMTALA complaint. A delay in admission can create implications for accreditation. The Joint Commission integrates performance measurement data into their accreditation process. Performance measures for the ED include the median time from ED arrival to ED departure for admitted ED patients and admit decision time to ED departure time for admitted patients. Delayed decision time on admit or transfer for a patient who has a narrow network could make the performance on these performance measurements worse. But consider this: you may actually have a health plan in violation of the federal No Surprises Act, Medicare Advantage rules, and/or potentially your state law’s equivalents. Under the No Surprises Act, health plans must generally cover emergency services in a hospital and post-stabilization services. Further, they must do so without requiring prior authorization. The facility should ultimately be paid what is called the qualified payment amount – an amount determined by a formula under No Surprises Act regulations to inform health plans on payment amounts since there is no contracted rate between the plan and the hospital being excluded from a narrow network. The No Surprises Act applies to group health plans, health insurance issuers offering group or individual health insurance coverage, and carriers in the FEHB Program. Nearly identical requirements to cover and pay for emergency and post-stabilization services apply to Medicare Advantage plans and are also usually addressed under state Medicaid and Medicaid Managed Care organization plans. CMS offers a great FAQ with contact information to ask questions about state or federal laws. The No Surprises Act is managed and enforced by CMS. To submit a complaint of a plan’s potential violation of the No Surprises Act, visit this CMS site. Your organization will help determine whether you should proceed with admission, or determine a stable patient is appropriate for transfer to another facility. Your system’s risk management or legal counsel should be consulted to help evaluate what risk is more reasonable when dealing with narrow networks: risk an EMTALA complaint even if unfounded, or risk not being paid for admitting the patient. Alongside whichever path your organization chooses, there are parallel means of addressing the issue through filing complaints with CMS, the Department of Insurance, state Medicaid agencies, etc. |