Emergency Medicine Reimbursement Update*


Written by John G. Wallace, Jr MD, FACEP, DABIM
President/Treasurer IEPC

This article was originally published in the August 2023 IEPC Newsletter. Click here to view a PDF of the newsletter.

*Abstracted from the CAL ACEP Reimbursement Committee

  1. MEDI-CAL Rate Increase
    • $35 Billion budgeted for 16 million California Medi-Cal patients is the largest investment in Medi-Cal ever
    • Largely paid for by MCO Tax on health plans
    • First rate increase in 20 years increases Medi-Cal rates to 87.5% Medicare
    • $1 Billion Primary Care
    • $1 Billion Specialties primarily women and childcare
    • $700 million Behavioral Health and $300 million for additional beds
    • $200 million Emergency Services
    • Conjoint effort of CMA, CAL ACEP and 600 MDs who contacted legislators
    • Scheduled for 2025 and need vigilance to make sure bill is funded with possible ballot issue to ensure funding doesn’t disappear.
  2. NSA
    • EDPMA developing document to present to US Sec of Health Becerra to change the flawed IDR procedure
    • IDR Health Plan Tricks:
      • HPs apply payments from IDR to patient’s deductibles and therefore MDs can’t bill patients
      • HPs tell MDs to bill patients which violates NSA
      • HPs either no pay, pay less than award, or charge patients
      • HPs pay patients not Providers
  3. Anthem No Pay-Anthem ABX “Special Investigations Unit” Pre payment Review Program (PRP)
    • Denying EKG payments as not part of MDM
    • Workup not what you do but what you recommend e.g. ordering CT not part of workup but recommending another MD order CT is. Inappropriate application of Marshfield Audit Tool
    • Payment based on final diagnosis as risk determinant which violates prudent lay person
    • CAL ACEP- 2 meetings with DMHC
    • DMHC requested IDR which is flawed response: 1. voluntary for HPs in California and 2. Arbiter can’t determine methodology of payment employing Gould Criteria
    • Kaiser told DMHC they had increased % of payment when in reality had changed the payment metric from billed charges to allowables which caused a 50% decrease in payments. Kaiser skirted this in discussion with DMHC.
    • Go Forward: DMHC to re-contact Kaiser