Virginia Docs Get Just $15 for Certain Medicaid ED Visits

Virginia emergency physicians are fighting what they call unfair Medicaid reimbursement rates tied to an “overutilization” initiative that misses the mark.

Nearly 2 years ago, a budget amendment slipped through the Virginia legislature that ordered some 800 diagnoses seen as “avoidable” emergency visits to be automatically downcoded for Medicaid patients treated in the emergency department.

Physicians would earn just $15 for each encounter — including for things like diabetic ketoacidosis, heart failure, and newly diagnosed brain tumors, tweeted Kimi Chernoby, MD, JD, an emergency physician in Virginia.

“That means, if you come into the Emergency Department for one of those life threatening reasons, your ED physician gets paid less because Medicaid thinks it could have just as well been treated in a different setting,” Chernoby tweeted. “Despite the fact that all 3 of those diagnoses can require ICU.”

Cameron Olderog, MD, president of the Virginia College of Emergency Physicians (VACEP), told MedPage Today that asthma attacks are also on that list.

“It would make sense that if someone had great primary care access and well-controlled asthma, they should have fewer attacks,” she said. “But if someone is having an attack and they can’t breathe, they need to come to the ED.”

Olderog acknowledged that emergency department overuse among Medicaid patients is certainly a problem worth addressing, but penalizing doctors isn’t the way to accomplish that goal.

Multiple factors play into poor primary care access among Medicaid patients and they need to be addressed at a systemic level, she noted. Part of the problem is that primary care reimbursements for Medicaid patients are so low that physicians need to have large patient panels — so it’s not easy for patients to ask their doctors to slip in a last-minute appointment for something urgent.

“If a parent calls because their kid has a fever and is crying in pain, it could be a week before that kid can get in,” Olderog said. “That’s scary for a parent to have to wait.”

If that child is brought in to the emergency department, and they’re ultimately diagnosed with strep throat, for instance, the visit would be downcoded — even though it could have been a true emergency, she added.

Sara Rosenbaum, JD, of the Milken Institute School of Public Health at George Washington University, who is an expert in Medicaid policy, called the $15 reimbursement “draconian,” noting it’s “not the first time that Medicaid programs have tried to use payment as a tool for behavior change.”

“The problem is that many of these conditions present as an emergency until an individual is screened,” she added.

There are no financial ramifications to Medicaid patients, but Rosenbaum explained that EDs are “vast moneymakers” for hospitals. Technically, under the Emergency Medical Treatment and Active Labor Act (EMTALA), they are only required to screen patients for emergencies and stabilize them.

“It’s perfectly lawful to screen and say, ‘You’re sick, this is not an emergency, so we can’t treat you here. You’re stable so you have to go 12 blocks from here to the 24/7 urgent care center,'” she said.

VACEP and others have been attempting to challenge the provision. In August 2020, VACEP, the Virginia Hospital & Healthcare Association, and the Medical Society of Virginia filed a complaint against the Virginia Department of Medical Assistance Services in an effort to force an injunction of the utilization program.

When the suit was dismissed a few months later, the organizations filed an appeal, which was argued in March and still awaits a decision, Olderog said.

The groups also sent a letter asking CMS whether the state will be granted a plan amendment to allow the program to continue. Originally, language in the amendment allowed it to start without CMS approval on July 1, 2020, according to VACEP.

VACEP is also focusing on “key House of Delegates members to make this a budget priority,” according to a press release.

Olderog called the move a violation of federal prudent layperson standards, which were passed in 1997 to prevent insurance companies from denying coverage if they determined an encounter wasn’t an emergency.

Before the law, patients were ending up with huge balance bills, she noted.

Now, she said, the Virginia amendment is “impacting particularly hard those hospitals with a high percentage of Medicaid patients.”

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