Denial of emergency department authorization of potentially high-risk patients by managed care

• Published in: The Journal of emergency medicine 1997-09, Vol.15 (5), p.605-609
• Main Authors: Zautcke, John L., Fraker, Lesa D., Hart, Raymond G., Stevens, Jeremy S.
• Format: Article
• Language: English
• Subjects: access; Adult; Analysis of Variance; Biological and medical sciences; Chicago; Economy. Management; Emergency Service, Hospital - economics; Emergency Service, Hospital - statistics & numerical data; gatekeeper; Health and social institutions; Health Care Surveys; health maintenance organizations; Health Maintenance Organizations - economics; Health Maintenance Organizations - statistics & numerical data; Health Services Accessibility - economics; Hospitals, University - economics; Humans; Insurance Coverage - statistics & numerical data; Insurance, Health, Reimbursement - statistics & numerical data; managed care; Medical sciences; Public health. Hygiene; Public health. Hygiene-occupational medicine; Retrospective Studies; triage; Triage - standards
• ISSN: 0736-4679; 2352-5029
• DOI: 10.1016/S0736-4679(97)00120-0

This study was designed to evaluate patients presenting to a large urban university emergency department (ED) who were subsequently denied authorization for reimbursed care by their managed care provider and to characterize the denial as potentially safe or unsafe based on published triage criteria. A consecutive case surveillance was performed from October 1, 1994 to September 30, 1995 at a university-based ED (30,000 visits per year) for adult patients in inner-city Chicago. Cases were comprised of adult managed care participants whose providers refused by telephone to authorize payment for ED services and who then left the ED without treatment. Chief complaints and vital signs were used to categorize patients as high-risk or nonemergent based on previously published criteria. A total of 2,965 adult managed care patients presented to the ED during the study period, representing 11.1% of the total ED census. Of these patients, 244 (8.2%) were denied authorization for payment of their care. By previously established criteria, 115 (47.1%) were identified as potentially unstable, 61 (53%) due to abnormal vital signs and 54 (47%) with other high-risk indications such as severe pain, chest pain, or abdominal pain. These potentially highrisk patients may subsequently suffer adverse outcomes. Current guidelines used for telephone triage by managed care to divert patients from our ED do not meet previously published safe triage criteria.