Articles

Click here to view a PDF of the August 2025 IEPC Newsletter

In this issue:

• President Pearls – NSA and Payment Leaks
• Vaccine Screening in the ED
• Hanging Up the Stethoscope
• 2025 IEPC Speaker Series

Roneet Lev, MD, FACEP
Executive Director, IEPC

It’s not easy to hang up the stethoscope. For over 30 years, emergency medicine has been a core part of my identity, woven into more than 100,000 patient encounters. It’s never just been a job — I carry it with me everywhere. At home, as a mother and wife, I instinctively triage which child to help first, rule out worst-case diagnoses when someone is ill or injured, and manage the crisis of the day. Prevention is everything: better to treat respiratory distress early than intubate later; better to prevent a child from becoming hangry — or hurt — before it escalates.

Even at 30,000 feet, the call for help draws me in. When someone asks, “Is there a doctor on board?” I’m out of my seat. As my kids grew up, they started volunteering me. Once, my husband and I were seated in first class while our four children were in coach. When a passenger became sick, they immediately volunteered me. My son earned a seat in first class for the rest of the flight, and I spent the duration attending to the patient.

On October 7, 2023, I was at the ACEP Conference in Philadelphia. But I couldn’t focus on any lecture or event. My heart was in Israel, reeling from the most violent and heinous attack on its people since the Holocaust. I did everything I could to get there as an emergency physician. I was fortunate to go several times — training others, supporting a search and rescue team, riding ambulances, and working in emergency departments.

I love emergency medicine. Yes, I’ve been assaulted — twice — knocked to the ground by patients. The SWAT team was called: “911, doctor down.” Yes, I’ve had frustrations with hospital management. I’ve had patients threated to sue me or have me fired. Still, I have no regrets. That’s the nature of the emergency department — it’s intense, unpredictable, and profoundly meaningful. I recommend the specialty to anyone who can multitask, who wants to make an impact with every shift, and who values practical, everyday medical skills. We are medical detectives who overcome any unpredictable challenge thrown our way. Emergency physicians are society’s heroes. The public recognized that during the COVID-19 pandemic — but it’s true every single day, with every patient we care for.

This isn’t how I envisioned ending my EM career. I imagined myself as a little old lady, 5’1” (maybe shrinking to 5’0”), ordering a B52 cocktail at the bedside of a violent, combative patient kicking and spitting — surrounded by six large staff trying to hold them down. But life had other plans. First came thyroid cancer, then a meningioma. I underwent two major surgeries in one year. I’,m proud to say that physically, you wouldn’t know it — but I had to face reality. Could I keep up with fast-paced 10-hour shifts on my feet? Could I adapt to new systems, new computers? (The new computer really stresses me out).

I explored EM-adjacent carer paths. Then, the answer arrived.

I’m honored and grateful to have accepted a position at the White House, in the Office of National Drug Control Policy, where I will oversee public health policies.

Is it challenging to work under a Trump administration? Honestly, no — it’s an honor. Unlike the emergency department, I can eat lunch, take a bathroom break, and am surrounded by excellent security.

This new role requires me to step back from consulting and volunteer work, including my role as Executive Director of IEPC, where I was a founding member. My heart will always be with IEPC, and I’m thrilled to pass the baton to Kavitha Weaver. Kavitha has been part of IEPC since the beginning. She understands the mission deeply and has my full confidence. I know she’ll lead and grow the organization with vision and strength.

Writing this is not easy. It forces me to admit that I am officially hanging up the stethoscope. But one thing I know for sure:

you can hang up the stethoscope — but you never stop being an emergency physician.

Roneet Lev, MD, FACEP
Executive Director, IEPC
With contribution from Dr. Les Berson

This story is heartbreaking — tragic for the patient and for the emergency group that lost its contract over a pediatric case gone wrong.

You be the judge…

December 2024 – A 14-month-old presented to the emergency department with intermittent fevers and reportedly “stiff neck.” The child appeared well-nourished, well-hydrated, afebrile (axillary), with a heart rate of 130, respiratory rate of 28, oxygen saturation of 99%, and in no distress. On examination, the neck was supple with no nuchal rigidity. The lungs were clear. The child was sitting on the mother’s lap eating Goldfish crackers.

A respiratory swab and urinalysis were negative, except for 1+ ketones in the urine. the patient was evaluated by a mid-level provider. The medical decision-making documented a viral illness; the diagnosis listed was “fever.” The child was discharged home without a physician review.

Thirty-six hours later, the child returned. (Don’t we all dread that? The patient always returns in the scary cases). This time, the child was lethargic and vomiting. The axillary temperature was 37°C, but rectally is was 38.5°C. Heart rate was 153, respiratory rate 22, and oxygen saturation 100%.

At this point, all the big guns were pulled: blood work, lumbar puncture, IV fluids, intubation, head CT, antibiotics, oxygen, consultation, and transfer to a pediatric hospital.

Abnormal labs showed:

• WBC: 1.4
• Hematocrit: 30.6
• Potassium: 3.2
• Anion gap: 20
• BUN: 18
• Creatinine: 0.5
• Lactic acid: 3.6

Chest X-ray showed no infection. CSF PCR was positive for Streptococcus pneumoniae meningitis.

The diagnosis: pneumococcal meningitis — consistent with lack of vaccination.

So what is the Quality Improvement lesson here?

• Should all infants have a rectal temperature taken in the ED?
• Should all children be evaluated by an attending physician before discharge?
• Should we start asking about vaccination status in febrile children?

Currently, EDs do not routinely inquire about vaccination status in pediatric patients. However, vaccination rates have declined — down 2-3% from pre-pandemic levels (2019) to 92.5% in kindergarten-aged children in 2024. For toddlers (age 3), the rate is even lower, around 72-73%.

Perhaps it’s time to add a new review-of-systems question: vaccine status — especially for young children presenting with fever.

This case was a sentinel event for the hospital. The emergency department was blamed, and the incident led the administration to terminate the ED group’s contract.

Robert Chavez, MD
President, IEPC
Providence Little Company of Mary Medical Center Torrance

Hello friends and colleagues,

For those of you engaged in the No Surprises Act IDR process, there is a recent bit of good news you may want to alert your revenue cycle management company about. This is regarding your past out of network claims previously ineligible for IDR due to deadlines to submit IDR claims. Due to widespread non-compliance by payors who failed to include required information on EOBs and remittance advisories, specifically details mandated by CMS under the No Surprises Act (NSA), there is now a pathway to submit eligible claims from 2022 forward.

This is important because CMS guidance expects payors to include specific IDR-related data in payment determinations. However, many payors failed to do so. As a result, this may extend your eligibility window for initiating IDR on older claims. If you or your revenue cycle management company didn’t file claims or missed IDR deadlines due to missing or incorrect information from a payor, those claims may now be reviewed. If you think you may have eligible claims, alert your team member or RCM company who manages IDR process as soon as possible to see if any of your claims qualify. This is a narrow window and is expected to close once CMS and payors tighten enforcement.

Click here to view a PDF of the May 2025 IEPC Newsletter.

In this issue:

• President Pearls – NSA and Payment Leaks
• Strategies for Sustaining Emergency Care in the United States
• Tips from the Southern California Wildfires
• California ACEP Legislative Agenda
• Screwed as a Doctor and Now as a Patient
• 2025 IEPC Speaker Series

Roneet Lev, MD, FACEP
Executive Director, IEPC

At IEPC, as in most emergency medicine organizations, we spend much time defending our reimbursement. IEPC members along with physician groups across California have been in litigation against Blue Cross for systematic payment denial of level 5 visits. The American College of Emergency Physicians (ACEP) and the Medical Association of Georgia sued Blue Cross Blue Shield and Anthem for reclassifying emergency room visits as non-emergent retroactively.

Health plans have a reputation of screwing emergency physicians.

Recently I was on the other end of medicine, as a patient. I have written about that the final emotional aspect of going from doctor to patient in the past. This time I share the financial aspect of being a patient.

In the past year I had a thyroidectomy with a neck dissection and more recently a craniotomy for meningioma. Please don’t worry – my medical recovery is great, and I have a great prognosis. It will take more to kill me. But recovering from the financial hassles is worse than any post op pain.
In the stack of mail that I went through while recovering was an insurance denial letter of my Brain MRI. Who denies an MRI to someone with a brain tumor? I saw they listed cause of denial, was thyroid. It had to be a clerical error. I called to clarify. Aetna outsources its medical approval process to eviCore. After several phone transfers, I reached the customer service supervisor who identified herself as my “patient advocate.” I was informed that the MRI is indeed denied because they consider it experimental, and they do not cover experimental procedures.

I send a complaint to the California Department of Managed Healthcare saying that Aetna is practicing medicine without a license and interfering with patient care by denying the MRI. To no one’s surprise, I never heard back.

How many patients who are not able to defend themselves suffer from egregious denials?

In any case, I can say that I have been screwed by the health plans as a physician and as a patient.

I must add that the hospital is not a angel in the medical financial system. Their portion of a thyroid biopsy was $15,067.31. The radiologist charged $229. The hospital charged $869 for a pre operative Chest X-ray. I could not negotiate any of these crazy prices, and I tried. Hospitals still put fear of sending you to collections for non-payment.

As the singer Joe Walsh has said, “I can’t complain but sometimes I still do, life’s been good to me so far.”

Elena Lopez-Gusman
Executive Director, California ACEP

California ACEP members went to Sacramento to lobby their congressional leaders. The following is a summary of the sponsored legislation.

AB 447 (Gonzalez) – Reducing Medical Waste & Saving Healthcare Dollars
Patients often present to the emergency department (ED) with conditions that require administering medication to them while in the ED. Sometimes these medications, like eye drops, inhalers and liquid antibiotics, contain more doses than will be used during the duration of the
ED visit, but they cannot be used on another patient. Under existing law, the remaining doses cannot be sent home with the patient they were administered to, so they must be thrown away.
Patients who receive these types of treatments leave the ED with a prescription for the same medication that they must pick up and pay for at an outpatient pharmacy to continue treating their condition. Current law results in redundant prescriptions, increased cost to the health system, and increased medical waste. AB 447 allows patients to take home the remaining doses
of their multiuse medication.

AB 416 (Krell) – Reducing Delays in Care for 5150 Patients in the Emergency Department
One in 6 patients that comes to the ED has a behavioral health diagnosis. Many of these patients are seeking care voluntarily. Some can be stabilized, treated and discharged home after. Some of them need additional community services and in conjunction with the social worker in the ED, can be connected to those services. Some need to be transferred to an inpatient facility. Because they are voluntarily seeking care, emergency physicians can immediately begin looking for placement. There are additionally a smaller number of people who are a danger to themselves and others and need to be placed on a 5150 hold to ensure they remain safe and to get an additional assessment and care at an LPS designated facility as required by law. Emergency physicians cannot start looking for an available bed in an LPS facility until the patient is placed on a 5150, which in some places can take many hours, even days. 5150s are placed by county designated authorized individuals. Who is authorized varies by county. Thus, there is a wide disparity in resources available to providers and to patients, and in the difference in time patients wait depending on the county, or even the time of day, or day of the week they are in crisis. Emergency physicians are always present in the ED. AB 416 empowers emergency physicians to care for their patients by allowing them to apply and train to be county designated individuals authorized to write 5150 holds.

Delays in Proposition 35 Funding Are Crushing Emergency Departments
California ACEP respectfully requests the Legislature maintain its commitment to the emergency care safety net and include $100 million for increasing Medi-Cal rates for emergency physicians as previously approved in the 2024-2025 budget.

Summary of an Interview with
Dr. Larry Stock, IEPC member,
Antelope Valley Hospital

On January 7, 2025, IEPC member Dr. Larry Stock lost two homes, his and his parents.’ The Southern California wildfires killed at least 30 people and destroyed more than 18,000 homes. The Palisades Fire was one od the largest fires and where Dr. Stock lived.

Here are some of his fire victim tips that include: 1. Watching, 2. Preparation, 3. Taking Off, and 4. Recovery.

Tip 1: Watching

Watch duty is the application used by fire fighters and available to the public. This is the best source of tracking the fires, the perimeters, power outages, and more. The other watching source is wind direction. Knowing where the fire was and the wind was going allowed for the best decision on whether to evacuate, fight the fire, or continue to monitor.

Tip 2: Preparedness

It is a good idea to digitize important documents such as Passports and insurance policies and keep them on the cloud. After a fire, you are asked to itemize everything that was lost. Taking a video of your house, including opening drawers and recording the contents makes that process mush easier. That video should be on your phone or on the cloud where is not a victim to the fire. A firesafe is not always fireproof. It is advised to think ahead on what you would take out of your home if you had 5 minutes, if you had 1 or 2 hours. Some people prioritize pictures and mementos. Others go first for the computer and documents. Larry had one hour and one car load of things to get out.

Tip 3: Taking Off

Emergency Physicians are givers. Our nature and profession are serving and helping others. Being a fire victim, Dr. Stock was in the uncomfortable position of receiving. He evaluated with only the clothes on his back and did not have time to go shopping with all the other tasks that were a priority. He felt like he was dropped off on Earth and had to restart. Larry pivoted from giver to and receiver. His friends provided shelter, clothing, and support in the immediate aftermath.

Tip 4: Recovery

There are great frustrations in dealing with fire insurance, government assistance, and rebuilding. They continue to this day and are a full-time job. Larry stayed with friends, an Airbnb, and now is renting a house previously owned by Clark Gable. He is still working on a permanent residence. FEMA and government assistance was promised to many fire victims. One attractive program was through the Small Business Administration offering a $500,000 loan with 3% interest and a 30-year term. Larry describes going through a financial colonoscopy of personal information to apply for this loan. After two weeks of intense application, he was informed that people with good insurance and resources were not eligible. It would have been nice to know that at the beginning.
Larry points out a major benefit of being part of an independent group. His emergency physician partners are his brothers and sisters. They protected him. His group gave him 6 weeks off before returning to a reduced schedule. To his surprise, they also paid him during those 6 weeks as though he was working. That degree of empathy and kindness is rare in the workplace.
Losing a home is a phychosocial and financial toll. It’s a trauma. Thankfully, as an emergency physician, having resiliency and ability to make important decisions with incomplete information is our asset. Dr. Stock remains optimistic.