Successful ED throughput in today’s world


Written by Scott Adler
Insight Strategies, LLC

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

In most hospitals, more than half of all patients on the inpatient units come via the Emergency Department. If the front door of the hospital doesn’t facilitate great care and a great patient experience (for those discharged as well as admitted), it can be very difficult for the hospital to recover. Unfortunately, stories about struggling EDs have become the rule rather than the exception across the United States. Additionally, these struggles are only exacerbated by the increased volume finding its way to the ED after COVID. Throughput (length of stay), door-to-provider times, patient and staff engagement, left without being seen (LWBSs), elopements, inpatient holds, and diversion hours frustrate clinical staff and administration alike. While there are numerous methodologies that can be used to address these issues (Lean, Six Sigma, etc.), it is important to recognize that regardless of the way in which the problems are addressed there are only a handful of habits that are required for an ED to be successful.

Bringing these habits to life requires changing old habits—both organizationally and in the ED. There are two essential aspects of change that must be adhered to if an ED is able to successfully acquire these habits—engaging front-line caregivers in the design and considering the ED as a system, not a series of discreet steps.

Working with facilities large and small (currently more than 5 million patients are experiencing care each year in facilities whose process redesigns I’ve facilitated) I’ve seen what works. Not a specific process (there are differences site to site depending on a number of variables) but a set of habits that successful EDs take advantage of. Each of these habits is connected and reinforces the others. They sound simple. But don’t be deceived. They aren’t necessarily easily acquired or executed. Here are a few words on each:

Be truly patient focused

Patients come to ED for only one reason—to see a provider. We may know this intellectually, yet we put up roadblocks between the door and the provider. These roadblocks are well intended and make sense when we establish them, but we don’t fully comprehend their unintended consequences (for example, in most EDs, the first person the patient walking in sees isn’t a clinician—it’s a registrar or a security officer). Before you can be truly patient-focused, you have to know what patient-focused really looks like. That doesn’t mean which questions are identified as most important on the patient sat survey. It’s really knowing and understanding what the patient requires—what they want, need and expect—of the service you’re providing.

It is vital that you engage front-line staff in clearly articulating the ideal patient experience and use that as a filter for the process you employ to take care of your patients. Everyone must know what is expected of them and what they’re collectively shooting for.

Creating patient-focused processes isn’t always easy. Clinicians are smart. They’re able to rationalize why what’s best for them is, in fact, what’s best for the patient. That’s why most of the processes you find in health care are built around the staff, not the patient.

Have a source of truth regarding the process

Reducing variation is key to high-quality care and consistent, efficient and effective throughput. There needs to be a source of truth regarding how things are done, including expectations for performance. That means the care process should be documented to the task level because this will drive:

  • Consistency in performance
  • Consistency in training
  • Reduction in variation

This is about more than policies and it’s more than an oral history. If everyone is going to row in the same direction, they need to know specifically what the process is. Too often, the process that the new staff is oriented to is based on how the preceptor does it. If there are more than one preceptors, there will be variation baked into the training. “This is how I do it,” shouldn’t be the standard operating procedure. How it’s done should be in writing.

View the ED as a system, not a series of discreet events

Everything that happens in an ED (or in any system) affects other aspects of the system down stream. You have to address the entire system. In this case, it’s the ED process from arrival to discharge/admit (i.e., you can’t fix triage in isolation). Therefore, if you want to improve the system you need to do three things:

  1. Get the system in the room
  2. Give the participants a chance to see reality through each others’ eyes. This provides the participants an opportunity to suspend the assumptions they have about the other functions in the system (i.e., the ED RNs understand why the floor RNs might not want to or be able to take admitted patients as quickly as the ED RNs might expect).
  3. Allow the functions to put their different purposes together and to commit to them

Remember, it’s about improving the quality of thinking and interactions between the different parts of the system, not optimizing any single aspect of the system.

Ensure the patient is always where the patient belongs clinically

Unfortunately the processes that are in place are often based on incorrect assumptions. For example, our overarching mental models tell us that ED patients need to be in a bed to be treated. That’s why in most EDs patients have to end up in a bed before they see a provider or RN even if they don’t need to be horizontal for their care. The fact is, not every ED patient needs a bed to be treated and not every ED patient needs to own that bed throughout their stay if they should happen to get one at some point in the process. ED patients may physically move through their treatment experience. This concept leads to the consideration that the physical plant can be used more efficiently with the creation of results waiting or other “vertical” space for the patients, such as treatment in progress. However, in order for this to happen, understanding the acuity of patients and where they are in their treatment process is required, otherwise patients will get “lost” in the system.

Treat the sickest patients and manage the rest continuously through to disposition

The traditional process used by the overwhelming percentage of EDs forces clinicians to choose between patients based on acuity. If patients are segregated by acuity based on clinical criteria (not solely ESI designation) the staff can care for patients on the patient’s time, not on the staff’s time. This is different than a fast track, which is typically based on ESI 4 and 5 patients and struggles to be sustained due to the subjective nature of the initial triage. It is more effective to utilize limited clinical exclusion criteria as well as ESI. This segregation of patients should not be time-based (i.e., all patients can get through in 90 minutes).

Full initial triage with an ESI sort will inevitably lead to the idea that “this patient can wait.” This assumes that the system requires patients to wait for care and with this mindset, they inevitably will.

Another trick EDs use is putting a provider in triage, which typically leads to redundancy in the process (if the patient can’t be discharged from triage, the patient often goes through another assessment by the physician in the ED to complete treatment and order additional tests) or a “drive by” interaction between provider and patient that doesn’t fully initiate the treatment process.

Robust air traffic control (facilitating proactivity)

If patients move during the course of their treatment, you have to know where they are physically as well as where they are in their treatment plan. This means someone must oversee the overall flow of patients. The charge RN should be this air traffic controller. Keep in mind that the charge role is a real function not simply a designation. He or she is not the department’s gopher—physically pushing patients upstairs or handling hard sticks. They must do what they are uniquely qualified to do and their duties must be specifically defined (standardized). They need to be able to look ahead and project ED bed/space needs hours in advance to avoid the last minute scramble whenever possible. Understanding the volume and the distribution of that volume over the entire day is a must and they need the tools to manage current volume and anticipate future volume.

A sustained sense of urgency

Every patient deserves a focused, quick (but not too quick) throughput experience. All too often, there isn’t a real sense of urgency throughout the day in Emergency Departments. Usually it takes an emergent patient (a trauma or highly acute patient) or when the ED is slammed before there is a real sense of urgency. It is absolutely essential to maintain that sense of urgency when the department is full or if it’s virtually empty. The struggle is to pick up the pace when needed, if things have been slow. A coach once said to me, “How you practice is how you play.” The same idea applies here. A consistent sense of urgency leads to better quality care and improved patient experience throughout the day, not only when volume goes through the roof.

Continuous communication with the patient and family

The patient and family (or care support system) must be kept in the loop as the care process unfolds. That means that they should be updated every 15 minutes or less, even if you can’t add anything new to what’s happening. Scripting is essential to support the staff in this communication. Too many times I’ve seen ED staff actually avoid talking to patients because they don’t know what to say as to why the process is taking so long. And when they do talk to the patient, it’s very tempting to blame other parts of the system (“Radiology takes so long” or “I’m waiting to get a hold of the floor nurse to give report”).

Closing thoughts

ED throughput struggles are real. Most of my clients tell me the problems they have in the ED are driven by the inpatient units not taking patients quickly enough, the ancillaries are too slow, or the behavioral patients are camped out there for too long. When I hear this, I remind them that typically 4 out of 5 ED patients go home. If you can address the 80% successfully, the other issues are inconveniences, not single points of failure.

When it’s all said and done, remember: It’s a team sport and there are different motivations for different team functions. RNs in EDs today, generally, are less experienced than they were 5 or 10 years ago, which puts pressure on the more experienced RNs as well as the providers. (Adding to the struggles, these new RNs are turning over at an accelerated rate.) The sense of burnout is real and connecting all caregivers to their “why” is essential. The caregiving team must be owners of the process, not renters. Articulating an intentional culture and then operationalizing that culture in the process is key.

Some of this might seem obvious. Some runs counter to conventional wisdom related to the way in which EDs approach their care process. Remember, the way in which we think about our work drives how we do our work. How we think about care in our EDs drives whether or not these habits go from ideas we understand intellectually to ways in which we consistently care for our patients. Challenging the conventional wisdom can be tough.

Please give me a call if you’d like to talk this through or if you have any questions.

“Have you been cheated?” Napa Valley Emergency Medical Group Take on Anthem


Written by Andrew Fenton, MD, FACEP
Napa Valley Emergency Medical Group

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

It was the height of the Covid-19 Delta surge when we first received a letter from the Anthem Blue Cross Special Investigations Unit (SIU). In the letter, Anthem wrote, “In the spirit of education and collaboration…” my Emergency Department (ED) group would be placed into their Pre-payment Review Program (PRP) and most of our Level 5 bills for care already delivered would be denied and not paid. A letter to the Anthem Blue Cross SIU resulted in a patronizing and dismissive response from them and reiterated their policy that they would not pay even one cent for what would be about 80% of our Level 5 charts claiming the Medical Decision Making (MDM) documented did not support the charge.

My group (Napa Valley Emergency Medical Group) is a small (seven partners) independent democratic group. We have tried to contract with Anthem Blue Cross (ABX) in the past but have never been offered more than the unsustainable offer of 120% of Medicare rates. We knew our percentage of Level 5 charts and our charges were average or slightly below average and it was unclear why we were targeted and placed into their PRP. What was clear was that, because ABX members make up a significant percentage of our patients, our group would take a substantial financial hit from the health insurer’s unprecedented action.

Through the Independent Emergency Physicians Consortium (IEPC) we found out we were one of many small, independent groups that were targeted by ABX. We also learned ABX forced both noncontracted and contracted groups into their PRP and refused to pay for the care of thousands of ER visits where their subscribers received care, costing emergency physicians millions of dollars across the state. We learned many groups came to together to rightly bring legal action against ABX and their unlawful behavior.

We reached out to our billing company, Physicians’ Choice (PC), who quickly noticed these denials and set up meetings with ABX. In these meetings, ABX PRP coders gave little reason why the MDM and charts did not justify the code other than saying “it just doesn’t.” We learned ABX PRP letters and staff appeared to be written and signed by people who had no experience in E & M coding and were primarily involved in their fraud division and law enforcement.

This understanding crystallized even further when we discussed our situation with the California chapter of the American College of Emergency Physicians (California ACEP). The Chapter had been meeting with legislators and wrote letters to the Department of Managed Health Care (DMHC), whose purpose is to regulate managed health care plans like Anthem Blue Cross. The Chapter correctly reminded the DMHC that health plans can deny reimbursement for emergency services only when they believe the care was never delivered or when the billing claim is incomplete. ABX was not saying that the services were never performed, nor that the medical chart and billing paperwork submitted wasn’t satisfactory, but instead was putting forth the novel theory that these claims were “incomplete” solely because the level of the coding attached to them. ABX even suggested their PRP was designed to eliminate provider “fraud” and upcoding. Apparently convinced or confused, DMHC took no action against ABX.

It was clear the potential impacts of these decisions by ABX, and the indecision by DMHC, could have devastating affects not only on my group, but all of emergency medicine. If the actions of Anthem’s PRP were allowed to stand and they could pay nothing, and if this spread to other insurers, and other groups, it could completely unravel the emergency care safety net. One could even imagine this spreading to other medical specialties.

My group concluded we could not afford to join the pending lawsuit against ABX, but we were committed to attack the problem from multiple fronts using all the resources we had at our disposal. First, we wanted to work with our hospital to find out if they were paid for the same emergency visits and at what level of coding. We knew we would need to continue to engage all of organized medicine at every level. We also decided we needed to reach out to our local legislators while working to highlight this injustice in the press.

When we were able to access the hospital data for the same visits where our claims were denied we learned that the hospital was being paid for the emergency services delivered. We also learned that in nearly all these visits, the hospital was being paid at the same level of coding as we were billing. Though the coding for hospitals for ED visits and for ED physician services are not identical they are similar (both coded level 1-5) and it was illogical for ABX to pay the hospital for a level 5 charge while denying the level 5 physician charge claiming it was fraudulent.

Because of the potential scope of the problem, and with this new information, we reached out to the California Medical Association (CMA) who had previously been working with California ACEP on this issue. We began a dialogue with them so that they could better understand our situation and we signed a Business Services Agreement with the CMA so that we could share information and so they could delve into the specifics of our problem.

We contacted national ACEP and met with national leaders to explain the unique nature of our issue, while showing how it was similar to other payer issues ED groups have faced in other states including groups in Indiana with ABX. Soon after, ACEP produced a letter to the California Congressional delegation and to the Centers for Medicare & Medicaid Services (CMS), co-signed by California ACEP, explaining the injustice. In the letter, ACEP highlighted how Anthem was attacking smaller, independent groups and that it was paying the hospital for the same visit while denying physicians fair payment.

With the assistance and participation of California ACEP, my partners and I met on multiple occasions with our State Senate and Assembly legislators to educate them about Anthem’s actions. We also met with the office of our local Congressman. After he threw out the first pitch at our local minor league baseball game, I caught up personally with my congressman to bend his ear about my group’s problem. They were all sympathetic that our small business was being targeted by a company that annually profits billions of dollars.

Collectively, we produced an article with me as author that was published in “MedPage Today” and which garnered significant social media hits and attention: With ACEP’s coordination, and with others, I completed a video interview highlighting the injustice of the ABX denials on Medscape: Additional interviews were undertaken with reporters from with New York Times, California Healthline, and Fierce Healthcare (though never published). The media attention reached the popular Dr. Glaucomflecken, ophthalmologist and comedian, who posted a tweet on Twitter making a parody of the ridiculous ABX denials that received over 6,500 “Likes” and 1500 “Retweets”:

Meanwhile, ABX continued its PRP and continued to deny payment on most of our 99285 claims. Many claims were over a year old. Our billing company appealed each denial. ABX required materials to be sent in via the US Postal Service so our billing company printed and sent entire charts, sometimes multiple times by certified mail after the charts were “lost” per ABX.

We continued to try to understand why our groups was targeted. We confirmed the percentage of Level 5 charts billed by my group and our charges for a 99285 were at or below average. We were able to deduce that almost all denied were patients discharged home. But the methodology ABX was using for coding charts was unknown and it did not seem to match with established coding criteria. We were unclear what we needed to do or what “pass rate” would need to be achieved to be removed from the PRP.

The CMA continued to escalate the issue and wrote a letter to the DMHC Director highlighting the illegality of Anthem’s actions. Soon after, a meeting was arranged with the DMHC. We were able to explain to the Department in detail our situation, and how the nonpayment by Anthem was impacting our practices. They seemed genuinely surprised that we had hundreds of charts in limbo and on appeal with no action by ABX. We explained that we had very little understanding why our groups were selected for the PRP, why certain charts were denied and what coding criteria was used, and how we could get out of PRP. We conveyed the impact Anthem’s “no pay” scheme was having on our small group and our ability to stay afloat.

We were hopeful DMHC would take an enforcement action against ABX, but they informed CMA and us that no action would be taken. Perhaps with DMHC coaxing, soon after Anthem reached out to us to arrange a meeting. The call was illuminating. ABX was represented by Carl Reinhardt, who oversees their PRP. We learned the Pre-payment Review Program was the idea of Bob Mays, Vice-President at Anthem Blue Cross, and Carl’s boss. We were told they review all our 99285 charts and only when their coders believed 80% of our charts were coded correctly would we be removed from PRP (our “pass rate” was 50%). Carl said they look at “fallouts” (patients discharged home) and these are the charts that are scrutinized. He said they use AAPC-certified coders who use AMA and CPT guidelines to review charts to determine the correct code based on MDM, but final diagnosis was an important part of their final decision on the code assigned. Wanting to learn more we set a date for another meeting where we would look at actual charts. 

Along with representatives from our billing company, I met with ABX PRP coders and the PRP leadership (Carl Reinhardt, Troy Bird, Richard Mossler). Bird and Mossler (whose names are on all the PRP letters we received) said nothing and kept their cameras off. Our billing company, Physicians Choice (PC), submitted four charts for review that we believed were downcoded, and Anthem submitted charts they said were upcoded.

Reviewing these charts, we learned that ABX was using a Marshfield audit tool to determine the complexity of Medical Decision-Making (MDM) and applying it in a manner like in primary care. As employed this tool gave no credit for workups performed in the ED and only the “workup planned” AFTER discharge, similar to a primary care doctor planning on a workup for a patient’s medical complaint. Our PC coders interpreted “workup planned” as the workup in the ED and ABX viewed this as workup recommended after leaving the ED. For example, in a patient with Chest Pain, higher complexity would be assigned by our coders if the patient received a Chest CT or serial EKGs/cardiac enzymes to rule-out life-threatening pulmonary embolism or acute myocardial infarction. Anthem would not give any credit if these tests were performed in the ED, and would only if they were instead recommended in the discharge paperwork (laughable logic).

We next learned that there was a significant difference between how our PC coders and the ABX coders determined “Risk” as it applies in the MDM contributing to the final billing code.  Our coders viewed “Risk” as the threat to life or bodily function associated with the Chief Complaint and Anthem viewed “Risk” as the threat to the patient AFTER the completion of the ED workup. Again, in an ED patient with Chest Pain, this would be considered by our coders as a high-risk complaint because the risk of heart attack (myocardial infarction) or multiple other dangerous etiologies. ABX stated because those high diagnoses were ruled out by testing in the ER and the patient is discharged, they are automatically at low (or moderate) risk. This reliance on Final Diagnosis is not new for payers underpaying physicians, but the logic Anthem applied as it relates to how charts are coded seemed to be a new wrinkle and clearly conflicted with CPT and CMS determinations.

One of the charts we submitted for review that was initially denied involved a patient with dysrhythmia treated and sent home (denied March 2022 and paid on appeal on May 2023, 14 months later). We were aware that part of Anthem’s PRP was the denial of EKG interpretations and that ABX was bundling this within the overall E&M code (though this was not supported by CMS and CPT that state that contemporaneous EKG interpretation is a separate billable service). In a detailed review of Anthem coders’ scoring of the chart we learned that they were also not giving credit for EKG interpretation in the MDM. It seemed their PRP team was ordered to not pay for EKG reads and this spread to how they coded each chart. Further discussion made it clear their coders were not giving credit for any ordering and interpreting of any cardiac electrophysiological tests (EKGs, rhythm strips, cardiac monitoring/telemetry) into the MDM. They were doing the same with bedside ultrasounds. Carl Reinhardt admitted this was a mistake and that ABX cannot deny payment for EKG interpretation and also entirely discount the EKG interpretation in the MDM.

The meeting ended with a promise of another meeting to discuss the impact of this revelation and other matters including the delays in the PRP appeals process, and how ABX is handling the new CPT guidelines for ED E & M codes. It was clear ABX had no defensible position for how they were coding charts and they admitted by mishandling EKG interpretations they wrongly downcoded most of the charts we reviewed. It was clear this had a significant impact on the final assigned CPT codes and this error would impact the codes assigned to charts by ABX as far back as 2021 when we were first placed into the PRP. We expressed to ABX that the admission by the PRP coders that the methodology they use in reviewing MDM is flawed would mandate that all denied 99285 claims that included an EKG or telemetry interpretation, or a bedside ultrasound, be re-reviewed by the PPR appeals team and be assigned a new updated code.

At the beginning of our third meeting with Anthem, Mr. Reinhardt informed us that my group would be removed from the Pre-payment Review Program. He again acknowledged that ABX and PRP coders have not been considering cardiac interpretations in MDM coding decisions. Rather than go back and investing resources recoding those charts it made business sense for ABX to just pay them and all the charts on appeal as coded by our billing company. Mr. Reinhardt also said he was aware that these errors in ABX coding has affected multiple groups in PRP and ABX will have to decide if they will go through each group’s denials and recode them.

We are now working with ABX to make certain that the backlog of unpaid charts gets paid. CMA continues to assist us in this regard and has had a number of meetings with the DMHC to review Anthem’s PRP program and its negative impacts. Part of this conversation is if DMHC will force ABX to pay the 15% interest owed on these unlawfully denied claims.

Meanwhile, I was recently contacted by an emergency medicine colleague in Kentucky whose small independent group was contacted by Anthem Blue Cross and informed they were being placed into Pre-payment Review. Like a weed, if these payer cheating tactics are allowed to exist, they grow and spread. Only when regulators, or the legal system, severely punishes them financially will they be less likely to hatch these schemes.

I am hopeful that with the new revelations of their flawed coding methodology, Anthem Blue Cross will roll back its Pre-payment Review Program entirely. In the meantime, I encourage any group in the PRP to contact the CMA, and California ACEP, and we have the contact information for Mr. Reinhardt who has offered to meet individually with each affected group. Reportedly, ABX is releasing an updated reimbursement policy for emergency medicine physicians that will take effect January, 2024. Meanwhile, the changes to CPT Documentation Guidelines for ED E/M Codes 99281-99285 are in force. These also include significant clarifications and the new guidelines state, “The final diagnosis for a condition does not in itself determine the complexity or risk as extensive evaluation may be required to reach the conclusion that the signs or symptoms do not represent a highly morbid condition.” The new guidelines will make it difficult for payers, like Anthem Blue Cross, to continue their practice of downcoding.

Running a small, independent ED group has many rewards, but also offers many challenges. One of the greatest is standing up to multibillion dollar insurance companies to be fairly reimbursed for the lifesaving care we deliver. To assist with this, it is vitally important we all work with one another as a team. This is one of the most important lessons I learned from this experience. By being involved with IEPC, California ACEP, and the CMA I have developed friendships and contacts that were invaluable when we came under attack. It also reinforced that our best friend was our billing company, Physicians’ Choice, who fought alongside us all the way. I also learned, that when threatened, though we are small group we can fight like a badger and must do everything possible to stay alive. We reached out to every ally we could think of, utilized the media and press, and looked for relief from the legal system, regulators, and politicians. Not only did I interrupt my congressman trying to enjoy a beer and hot dog at a baseball game, I submitted several cases to Judge Judy answering, “Have you been cheated?” In the end, it was all worth it.

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

2023 IEPC Speaker Series


Free to all friends of IEPC!

Presented by the Independent Emergency Physicians Consortium
Time & Date: 9:00AM – 9:30AM Pacific on the fourth Monday of the month.

Membership in IEPC is not required to attend. Advance registration for the meeting is required. After registering, you will receive a confirmation email containing information on how to join the call.

IEPC is proud to present the 2023 Speaker Series! This free speaker series has welcomed leaders in the field to cover timely and engaging topics that are important to independent emergency physicians. The sessions precede each monthly conference call and are open to all IEPC members and those who may be interested in joining. Upcoming sessions include: 

  • February 27 – Mike Granovsky, MD, CPC, FACEP – 2023 Documentation Guidelines: Best Practices and Strategies for Success 
  • March 27 – Sheree Lowe, MD – Emergency Medicine Practice Revenue Challenges Yesterday and Today with Proposed Solutions for Tomorrow 
  • April 24 – Sandy Schneider, BSPharm, PharmD – ACEP – Boarding 
  • May 22– Elena Guzman, MD – California ACEP 
  • June 26– Bob McNamara, PharmD, MSPH, FAHA, FHFSA, FCCP – American Academy of Emergency Medicine 
  • July 24– Scott Adler, Cand. philol – Insight Strategies, LLC 

This series is presented on the fourth Monday of the month January – November year. Advance registration is required and can be completed by registering through the monthly email invitation. After registering, you will receive a confirmation email containing information about joining the meeting. If you would like to join the IEPC mailing list, or want to invite a colleague, please visit 

Congratulations to the Newly-Elected IEPC Board Officials


EPC is excited to announce the new Board of Directors members for 2023-2024. 

Newly-Elected IEPC Officials 

  • President: John Wallace 
  • Secretary: Mike Gertz 
  • Vice President: Sameer Mistry 
  • Vice President: Don Shook 
  • Vice President: John Ellison 

Each official was sworn in at the January Board meeting, commencing their one-year terms. 

To all IEPC members – thank you for taking the time to cast your ballot. We appreciate your support in keeping the Consortium strong and moving forward in a positive direction. 

UnitedHealthcare Tried to Deny Coverage to a Chronically Ill Patient. He Fought Back, Exposing the Insurer’s Inner Workings.


by David Armstrong, Patrick Rucker and Maya Miller
Originally published on Feb. 2, 2023 on Pro Publica. Excerpt reprinted with permission.

Note from the Editor: What is wrong with this picture?
• On one hand health plans are reporting record profits but on the other hand hospitals are closing.
• On one hand 7 health insurance CEOs raked in a record $283 million last year but on the other hand emergency physician reimbursement is headed for a record decline in 2023.
• On one hand medical billing can run $2 million a year yet on the other hand a level 5 emergency physician fee is around $500. Emergency doctors, not hospitals are targeted for non-payment by health plans. Is it time for us to revolt.

In May 2021, a nurse at UnitedHealthcare called a colleague to share some welcome news about a problem the two had been grappling with for weeks. 

United provided the health insurance plan for students at Penn State University. It was a large and potentially lucrative account: lots of young, healthy students paying premiums in, not too many huge medical reimbursements going out. 

But one student was costing United a lot of money. Christopher McNaughton suffered from a crippling case of ulcerative colitis — an ailment that caused him to develop severe arthritis, debilitating diarrhea, numbing fatigue and life-threatening blood clots. His medical bills were running nearly $2 million a year. 

United had flagged McNaughton’s case as a “high dollar account,” and the company was reviewing whether it needed to keep paying for the expensive cocktail of drugs crafted by a Mayo Clinic specialist that had brought McNaughton’s disease under control after he’d been through years of misery. 

On the 2021 phone call, which was recorded by the company, nurse Victoria Kavanaugh told her colleague that a doctor contracted by United to review the case had concluded that McNaughton’s treatment was “not medically necessary.” Her colleague, Dave Opperman, reacted to the news with a long laugh. 

“I knew that was coming,” said Opperman, who heads up a United subsidiary that brokered the health insurance contract between United and Penn State. “I did too,” Kavanaugh replied. 

Opperman then complained about McNaughton’s mother, whom he referred to as “this woman,” for “screaming and yelling” and “throwing tantrums” during calls with United. 

The pair agreed that any appeal of the United doctor’s denial of the treatment would be a waste of the family’s time and money. 

“We’re still gonna say no,” Opperman said. 

More than 200 million Americans are covered by private health insurance. But data from state and federal regulators shows that insurers reject about 1 in 7 claims for treatment. Many people, faced with fighting insurance companies, simply give up: One study found that Americans file formal appeals on only 0.1% of claims denied by insurers under the Affordable Care Act. 

Insurers have wide discretion in crafting what is covered by their policies, beyond some basic services mandated by federal and state law. They often deny claims for services that they deem not “medically necessary.” 

When United refused to pay for McNaughton’s treatment for that reason, his family did something unusual. They fought back with a lawsuit, which uncovered a trove of materials, including internal emails and tape- recorded exchanges among company employees. Those records offer an extraordinary behind-the-scenes look at how one of America’s leading health care insurers relentlessly fought to reduce spending on care, even as its profits rose to record levels. 

As United reviewed McNaughton’s treatment, he and his family were often in the dark about what was happening or their rights. Meanwhile, United employees misrepresented critical findings and ignored warnings from doctors about the risks of altering McNaughton’s drug plan. 

At one point, court records show, United inaccurately reported to Penn State and the family that McNaughton’s doctor had agreed to lower the doses of his medication. Another time, a doctor paid by United concluded that denying payments for McNaughton’s treatment could put his health at risk, but the company buried his report and did not consider its findings. The insurer did, however, consider a report submitted by a company doctor who rubber-stamped the recommendation of a United nurse to reject paying for the treatment. 

United declined to answer specific questions about the case, even after McNaughton signed a release provided by the insurer to allow it to discuss details of his interactions with the company. United noted that it ultimately paid for all of McNaughton’s treatments. In a written response, United spokesperson Maria Gordon Shydlo wrote that the company’s guiding concern was McNaughton’s well-being. 

“Mr. McNaughton’s treatment involves medication dosages that far exceed FDA guidelines,” the statement said. “In cases like this, we review treatment plans based on current clinical guidelines to help ensure patient safety.” 

But the records reviewed by ProPublica show that United had another, equally urgent goal in dealing with McNaughton. In emails, officials calculated what McNaughton was costing them to keep his crippling disease at bay and how much they would save if they forced him to undergo a cheaper treatment that had already failed him. As the family pressed the company to back down, first through Penn State and then through a lawsuit, the United officials handling the case bristled. 

“This is just unbelievable,” Kavanaugh said of McNaughton’s family in one call to discuss his case. ”They’re just really pushing the envelope, and I’m surprised, like I don’t even know what to say.” 

To read the full text of the article please visit ProPublica here.

No More Emergencies


Dr. Glaucomflecken

Listen to the comic reality of emergency billing with No More Emergencies.

From the creator: Like all of my health insurance content, this is completely true. This is one of the more egregious examples from Anthem of blatant criminal activity, and it’s been going on for years. Remember, they don’t care about you. They just want to extract money from you any way they can. You can read more here.

Should I take an emergency physician job at Kaiser?


Within the protected Kaiser bubble, will I Thrive or Burnout?

Written by Anonymous IEPC member/contributor

Emergency medicine residency is hard. Residents and interns work many days and long hours. The work is often at county or community hospitals that treat a challenging patient population with a myriad of medical and social problems. Being on the frontlines facing a constant influx of patients with multiple complex issues can be daunting. At the end of residency, many young emergency physicians are ready for a break. The task of trying to start and build a career, at the end of residency brings even more stressors. 

It is during this time that many residents are offered career options. One option, chosen by many young physicians, is Kaiser Permanente. Kaiser Permanente is an HMO, consisting of the Kaiser Foundation Health Plan (the Kaiser insurance), Kaiser Foundation Hospitals, and the Permanente Medical Group (the Kaiser doctors). Patients buy the Kaiser insurance and they are only allowed to see Kaiser doctors. The Kaiser doctors (though technically their own medical group) are paid their salary solely by Kaiser Health Plan from the pool of insurance premiums, and so essentially act as its employees. 

Kaiser has a large presence in California and is aggressive at advertising to and recruiting graduating residents. Many graduates are uncertain about their future and are given no education how to go about job-seeking in California. They have little knowledge about how there are small independent democratic groups, large corporate-owned non-democratic groups (and everything in-between), and Kaiser. Trying to maneuver through this landscape and learn the nuances is challenging. It is during this time that Kaiser makes confused emergency medicine graduates their tempting offer. 

After what has been a physically and mentally taxing residency, and after giving so much acting as the very fabric of a health care and societal safety net within the ED, many residents look to downshift. Kaiser Permanente offers ED graduates a comfortable job, with a large increase in salary compared to residency, nice benefits, and employment in a large corporation where doctors can fill their role without the stress of running their own business. For a work-weary graduating resident, the idea of being a cog in the wheel in a relatively cushy job, while making a decent living, and receiving benefits, may be too hard to pass up. But, is the Kaiser offer all that it seems? Is the apple as sweet as it looks, or is there something inside the fruit unseen that is spoiled? 

Medical interns and residents exist in a system where they are clearly subservient to the Chief Resident, the residency director, and all the attending physicians. Just like in medical school, they are told where to be and when to be there. This structure provides organization and comfort to the chaotic work environment of an intern or resident. Kaiser offers a similar employer-employee model which appears familiar to young physicians. ED physicians within Kaiser receive a predictable salary and financial decisions are taken care of by others. Initially, this may reduce stress, but with time the lack of control and transparency of the revenues generated by one’s work can become frustrating. The comfort of the employed status is lost as one’s career matures, and the lack of autonomy associated with just being a “clock-puncher” can be disheartening. 

To a financially-challenged graduating resident, a Kaiser Permanente salary looks enticing. However, Kaiser ED physicians make significantly less than their colleagues in the more common fee-for-service model. What is also not advertised is that to achieve their full salary, Kaiser physicians must work full-time which is approximately 160 hours/month. Kaiser typically recruits new hires to their less desirable sites. This is similar to the other big groups like Envision, Team Health, Vituity, and USAHCS. Most of the highest paying sites at the best locations are run by independent groups (many members of IEPC) and Kaiser would like to keep this fact away from graduates. 

Kaiser is known for its benefit program. The package is designed to entice young physicians to say, “Yes” and once they become employed there exists large disincentives to leave. It is widely known in the ED physician community that Kaiser is famous for its “golden handcuffs” benefit package. If you are a recent graduate, and a young physician, and you work your entire career until you retire working full-time with Kaiser, these golden handcuffs can pay off in retirement. But for those who have lost the taste for the “Kaiser Kool-Aid” and who leave early the penalty is harsh, and the loss of many of the benefits makes the taste of those years of taking less salary at Kaiser even more bitter. 

Kaiser ED physicians primarily care for Kaiser members who are employed and well-adjusted. Overall, Kaiser members are savvy health care consumers and over-utilization of ED services is rare. Subsequently, though Kaiser ED docs have to work a lot of hours to make full pay, their day-to-day jobs are relatively easy. Kaiser avoids placing hospitals in poorer demographic areas to minimize walk-in Medi-Cal patients Therefore, Kaiser ED docs mostly care for responsible members with perceived acute care issues. Patient flow is predictable and ancillary services relatively abundant. Therefore, a Kaiser ED doc can take on a minimalist approach and function as a temporary stabilizing provider, and triage agent arranging for inpatient definitive care by others, or much more likely, follow-up visits through Kaiser’s network. Because most patients are employed and responsible community members the challenging social influences on a patient’s health, and their ultimate deposition from the ED, are minimized. The allure of an alternative comfortable job to a resident who has functioned for years giving heart, soul, and body on the frontlines as a safety net provider is attractive. 

But as many Kaiser ED physicians have experienced there are downsides to the minimalist approach to medicine seeing a healthier population. Kaiser ED physicians find their skills deteriorate not caring for the sickest patients. As a self-contained HMO, Kaiser is financially incentivized to discourage health care utilization, so Kaiser doctors are graded and financially rewarded or penalized based on test utilization. Admission rates are watched closely. Many patents talk about how Kaiser is a great health plan when you are healthy, just don’t get sick. 

A leading cause of burnout is the loss of feeling like one’s work is making a difference to other individuals and to society. All emergency physicians have an altruistic trait, and we chose our specialty because we know our work truly does change and save lives. Without the emergency safety net people truly would suffer and be lost. When an ED doctor chooses to join Kaiser, they carve themselves out of that world. Kaiser docs have chosen to practice medicine in a bubble buffered from seeing the poorest and sickest patients. After residency it is easy to think that it is time to take care of oneself and focus on supporting one’s family. But as one’s practice matures the loss of purpose and loss of satisfaction received when helping those most in need can be dispiriting and lead to burnout.

Kaiser Permanente has shunned its social responsibility and has had to settle a number of lawsuits where it removed coverage and shifted undesirable and poorer members to Medi-Cal. On rare cases in my ED, I find a challenging patient with socioeconomic problems with Kaiser insurance and my fellow ED docs and I always “joke” how long it will be until Kaiser figures this out and cuts them off. Ultimately this always happens and they are shifted to the county clinic and Medi-Cal. It is widely known that Kaiser discourages EMS providers from bringing homeless patients to their EDs while encouraging them to bypass closer hospitals when Kaiser members access the EMS system. Kaiser members are also instructed to go to Kaiser EDs possibly driving past a closer ED during an acute medical emergency. 

One of the most grievous offenses Kaiser commits is the way it handles transfers. All hospitals that participate in the Medicare program are required to follow EMTALA. Sadly, legislators and regulators have looked the other way allowing Kaiser to violate EMTALA on a daily basis. Kaiser has designed the EPRP system so that it only handles member repatriation transfers. Even though Kaiser hospitals have a robust on-call panel with multiple specialties they have shielded access to these physicians. On one occasion when I had a sick GI bleeder and no GI on-call I found the secret back-line to the nearby Kaiser ED where I knew they had GI available. After explaining the patient’s situation, the Kaiser ED doctor said they had GI and a bed but he wasn’t sure if he was allowed to accept a non-Kaiser patient. I was placed on hold and transferred to the house supervisor who hung up on me. When I called back the ED charge nurse hung up on me. The EPRP ED physician refused to discuss the patient’s case. Eventually the patient had to be transferred 100 miles away, driving past that Kaiser hospital to get there. Throughout the state, Kaiser hospitals refuse to participate in EMTALA and restrict access to some of the sickest patients needing medical care. This behavior is unlawful and unethical. 

Kaiser emergency physicians are required to take phone calls as part of EPRP (Emergency Prospective Review Program). California EMTALA law is clear that only a treating physician at the bedside can determine a patient’s medical stability. In violation of that law, and because of built-in financial incentives, Kaiser EPRP doctors frequently argue over the phone with treating ED physicians about a Kaiser patient’s stability while being treated at a non-Kaiser ED. These EPRP physicians (who have never seen nor laid hands on the patients) threaten to not pay for the medical care given to their members at the non-Kaiser hospitals. Even more unethical, Kaiser EPRP doctors threaten their own patients with large medical bills unless they agree to be transferred to a Kaiser hospital. These financial threats have forced emergency physicians to transfer patients against their will and despite the treating physicians’ medical judgment. These EPRP physicians violate the Hippocratic Oath to “first do no harm” and should be held accountable by the Medical Board and ACEP. Recently a Kaiser EPRP ED physician refused to authorize admission on a patient I saw with chest pain, arguing they were “stable”, threatening not to pay their medical bills and sending a fax saying they would stick the patient with the bill. Not longer after this infuriating phone call, the patient went into VFib and coded. We brought him back, but there was no guarantee that he would, especially if he was in the back of an ambulance or on a gurney mid-transport. 

Despite what Kaiser has tried to engrain into residents and doctors, there is nothing in California law that states non-Kaiser physicians have to waste time reading off labs and discussing cases with EPRP physicians. We did this as a courtesy. We are required to inform them of our working diagnosis and disposition decision (e.g., stable requires transport, unstable require admission). Hospitals are required to make one phone call to Kaiser when the decision is made by the treating physician. According to the California Health & Safety Code Section 1262.8 Kaiser then has “30 minutes” to call back. If they do not then even stable patients can be admitted to the non-Kaiser hospital and Kaiser must pay for both stabilizing and post-stabilization care. If EPRP agrees to accept the patient in transfer they must arrange for a “prompt” transfer. If they do not and they fail to transfer the patient in a “reasonable” time then the patient can be admitted and Kaiser must pay. 

The latest example of Kaiser’s refusal to play its part in the health care safety net is its drastic payment cuts to emergency physicians. Kaiser is well-known for refusing to pay or underpaying safety net hospitals leading to ongoing litigation. But Kaiser previously compensated non-Kaiser emergency physicians fairly when they provided life or limb-threatening stabilizing emergency care to Kaiser patients. This ended in June of 2022. Kaiser has slashed reimbursement to non-Kaiser ED docs in half without providing any justification. Fair payments to less-advantaged emergency departments was the very least wealthy Kaiser Permanente should do, and siphoning off these dollars to increase its profits will tear another hole in the fabric of the emergency care safety net.

Kaiser Permanente is one of the largest health care entities in California and is growing. They have been touted as a model HMO/ACO in the era of the Affordable Care Act. But Kaiser’s success is dependent on their model of caring only for the more fortunate members of society while shunning the poor. Graduating emergency residents in California are some of the best-trained in the country and have often endured a grueling residency. An employment offer from Kaiser Permanente, promising an easier job, carefree employee role, and a decent salary with benefits is very tempting. These young physicians should realize, however, that when they don the Kaiser golden handcuffs they sacrifice a higher salary, the autonomy of controlling one’s business, and the career satisfaction that comes with providing the expert care to those who need it most and only we can give. By joining Kaiser, emergency physicians also partner with an organization that behaves unethically, underfunds the emergency safety net, underpays its colleagues, and pressures its doctors to violate the Hippocratic Oath. The Kaiser apple may look sweet, but in fact the fruit has spoiled. 

Night Shifts: I Used to Love Them


Written by Katren Tyler, MD Clinical Professor of Emergency Medicine, Medical Director of Physician Wellness, Age-Friendly Emergency Department Physician Lead, Geriatric EM Fellowship Director, Vice Chair for Geriatric Emergency Medicine and Wellness, UC Davis.

Reprinted with permission from “Systems and Departmental Responses to Fatigue Management” SAEM Pulse, Nov-Dec, p50, Copyright 2022 by Society for Academic Emergency Medicine.

Many of us started our ​EM​ careers as bright-eyed​,​ twenty-somethings who had no problems with shift work, working ​multiple overnight shifts​ and rapid schedule ​transitions​.  And frankly, this is ​reasonably ​easy to keep up in our 30​’​s as well, even as our external responsibilities get more complex. And then your 40​’​s happens. 

Ludicrously, I have done two residencies in Emergency Medicine – one in Australia and one in the USA.  But in this regard, I am a​ ​bona fide expert – in my adult life, I ​have ​never not been a shift worker. As a resident in Australia, I spent more than 20 weeks in a year on a rotating night-float shift schedule and loved it. Night shifts: I used to love them. I was a night owl and proud of it. Until I didn’t and wasn’t. 

I don’t like night shifts anymore. I ​understand​ that we are a 24/7/365 ​business​. But now, in my 50’s, I am at my best early in the morning ​– the circadian opposite of being a nocturnist​  Night shifts are, without a doubt, my highest risk for a cognitive error at work, and I don’t think I am alone.   

Chronotypes are how sleep researchers describe your chronobiology. Your chronotype reflects your individual preference for going to sleep at night and getting up in the morning.  As much as possible, you should estimate your chronotype when you are free of the external responsibilities of your life​​ – work, kids, pets, all the business of modern life temporarily aside – ideally when you are on a vacation or at least on a non-work weekend.  For the most part, researchers classify chronotypes as early, intermediate, and late.  Sleep researchers recommend that we should try and make your work schedule match your chronotype. Obviously, this is a challenge in our specialty. For many people, our chronotype gets earlier as we get older and our tolerance for late and night shifts is reduced.   

In healthcare, we place most of the responsibility for coping with shift work on the individual healthcare worker. System and department wide responses to the impacts of shift work as we age, or experience other physiologic challenges are limited. My call to arms for fatigue management systems is that our lack of protections for shift workers are also likely harming our patients, and that surely makes it a systems issue. 

​​​​​We know that shift work is a burden for emergency physicians and their families in terms of circadian desynchronization and fatigue. The evidence is ​clear​: shift work, especially night shifts, get harder as we get older; night shifts are associated with short-term cognitive impairment across all industries. Moreover, longer periods of duty, especially longer night shifts, are associated with shortterm cognitive impairment and increased errors across all industries​.​ 

System suggestions: 

We have known for decades that sleep deprivation can be as serious as alcohol intoxication. It is unacceptable to be inebriated at work.  ​Yet we​ idealize and reward​ being exhausted​ in medicine. We have socialized and normalized fatigue in medicine for decades, recent changes notwithstanding.  

Healthcare in general, and ​EM​ in particular, has not acknowledged the cognitive load and patient safety risks of shift work.  There are very little systemic protections for physicians after training, and honestly, not that many protections during residency. We do not systemically evaluate if individuals tolerate shift work. Even if we acknowledge differences, we almost always put the responsibility on the individual. Multiple studies in healthcare and in other industries show people make more cognitive errors the longer that they have been awake. It will not surprise you to learn that other industries, especially the airline industry and some manufacturing industries have made stronger commitments to fatigue management than medicine has.  Sleep is the only way to reverse sleepiness. Fatigue management systems promote a shared responsibility between the employee and the system.  Sequelae of shift work include social jetlag / circadian desynchronization, cognitive impairment, and sleep disruption. Suggestions for protecting healthcare shift workers, and their patients, include evaluating the risks to ourselves and our patients, including pregnancy outcomes in health care workers, chronotype scheduling, access to sleep clinics, breaks on night shifts or extended shifts, access to food and water including cafeteria access, and the availability of call rooms or rideshare options.  Driving home after a night shift is a significant risk for motor vehicle crashes. We have work to do on the systemic role of sleep and aging physicians; most literature acknowledges sleep deteriorates with age, especially in shift workers

Departmental suggestions: 

As people age, our chronotype typically gets earlier, meaning we generally need to go to sleep earlier and wake up earlier​. We typically experience ​this change starting in our mid 40’s.  If you are lucky, you have some late chronotypes on your faculty.  Physiologically, late chronotypes can tolerate later shifts, including night shifts, with more sleep before and between night shifts.  Late chronotypes may struggle with early morning shifts.  Some individuals keep the same sleep-wake patterns they had when they were younger, are better able to tolerate shift work as they get older and are referred to as healthy shift workers

Many departments have night shift crews and incentivize the night shift: the night shift crews should be incentivized as much as possible in time or money.   

In our department, for some years, we have been able to opt out of night shifts at 55, and recently lowered the age to opt out of night shifts to 50 years of age.  This earlier opting out of night shifts at age 50 added 2-3 nights shifts per year to those faculty less than 40. 


​​​Pregnancy is a common physiologic challenge faced by healthcare workers and the health systems that employ them. Pregnancy outcomes are worse in shift workers and those working longer than a standard 40-hour week. It is harder to protect the first trimester because schedules are often in place before people know they are pregnant, but protecting the third trimester and ​parental ​leave periods should be more ​​straightforward than many ​EDs​ make it.  Our department has adjusted our shift requirements for pregnant faculty so that there are no required night shifts in the third trimester, and no clinical shifts in the emergency department after 36 weeks’ gestation.  As a department, we do have the option of telemedicine if pregnant faculty need to keep working clinical hours. Our health system provides 90 days of pregnancy leave for all faculty. 

Moving forward, we should think about how we collectively protect ourselves and each other from the impacts of shift work – for ourselves, for our colleagues and for our patients.