The Impact of Health Maintenance Organization Care Authorization Policy on an Emergency Department before California's New Managed Care Law

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Abstract
To examine the effect on patient care of HMO-mandated calls for authorization prior to ED evaluation. The study examined this phenomenon prior to implementation of a California law that discourages such calls. Concurrent data were collected for patients who presented to the ED and who had authorization calls made to their HMOs prior to their ED evaluations during the period September through December 1994. Data collected included: 1) the number of authorization calls made, 2) the frequency that ED care was deemed unnecessary by the HMO, 3) the outcomes of patients denied authorization, and 4) the time and personnel involved in completing calls. Follow-up phone calls were made to patients who left the ED after the HMO denied authorization for payment. The total ED census was 19,935 patient visits for the four-month period. Authorization calls were made for 4,642 (23%) of the ED visits. There were 545 patients (12%) in this group who had authorization denied and only 29 (5%) chose to remain in the ED for continued evaluation. The total time required to complete a call ranged from 20 minutes to 2.6 hours. Authorization calls and denials caused the following problems: 1) patients for whom calls were made were subject to delays in ED care; 2) at least seven patients referred to HMO clinics were referred back to the ED because the patient was too sick to receive clinic care; 3) patients were inconsistently asked to sign an against-medical-advice form when they chose to leave with unstable conditions; and 4) high-risk patients denied authorization included patients with final diagnoses of ectopic pregnancy, acute myocardial infarction, pulmonary embolus, respiratory failure, and sepsis. Calls for payment authorization prior to ED patient evaluation delay patient care and place some patients' health and safety in jeopardy.

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