Emergency Rooms, HMOs Clash Over Treatments and Payments : Medicine: Patients sometimes suffer as doctors struggle to get approvals and disagree over the level of care needed.


The pregnant woman arrived at Anaheim Memorial Hospital’s emergency room in the throes of a miscarriage, doubled over in pain and bleeding profusely. After a quick exam, the ER staff put in an urgent call to her HMO, Tower Health Services, with the question: How do you want us to treat her?

It was 2 1/2 hours, the doctors say, before the health plan called back. And for six hours after that, the physicians contend, the emergency room and Tower argued about who was responsible for the woman’s treatment.

Ultimately, Tower agreed to her admission. But Dr. Stephen J. Groth, the hospital’s emergency director, complains that the July, 1994, incident “appeared tantamount to abandonment.”

Towers’ medical director, Dr. Robert Cohen, disputes the hospital’s account. He insists that Tower physicians are on call during business hours to respond quickly to ER inquiries. But Cohen acknowledges regular disagreements between Tower and emergency rooms.


“We get used to this,” Groth said. “But when the patients are being asked to wait by their HMO and get jostled about, we’re the most visible persons for them to get angry at.”

Emergencies are among the few times when a patient must make a snap decision about where to go for medical care. That rarely causes trouble under traditional health insurance because most plans will cover emergency treatment wherever it is delivered. HMOs, however, generally insist that all care be delivered by their own doctors in their own facilities, or those under contract to the plan.

“If you make the wrong decision in the middle of the night and you go to the wrong emergency room, you’re not covered,” said Fred Dennis, immediate past president of the California chapter of the American College of Emergency Physicians. “But how many people know the right one?”

Patients have found their HMOs refusing coverage for middle-of-the-night chest pains that turn out to be indigestion, for broken ankles that turn out to be sprains, for post-accident CAT scans that come back negative. Emergency rooms, meanwhile, complain that HMOs raise administrative costs with burdensome demands for paperwork--and then delay payment for months.


Compounding the problem is most HMOs’ requirement that no care beyond what is necessary to stabilize a patient’s condition be delivered without advance authorization. ER physicians say finding an official to give the approval can take hours.

The only exception: Kaiser Foundation Health Plan of Southern California, which several years ago set up a special toll-free line that gives emergency rooms almost instant, 24-hour contact with a Kaiser doctor who has access to patients’ medical records and the authority to approve treatment.

The program processes up to 60,000 cases a year, said Dr. Jeffery Salevan, Kaiser’s regional coordinator of emergency medicine. Widely praised by ER doctors, the system almost always results in an agreement on the proper--and payable--course of treatment.

ER officials say a state law enacted to solve the problem has not helped. Since Jan. 1, California HMOs have been required to pay for emergency room visits as long as the patient had a “reasonable” expectation that his or her condition was urgent. Little has changed--because the state Department of Corporations, which regulates HMOs, has not promulgated regulations to implement the law.

“I still spend a full day a week appealing [payment] rejections,” said Daniel Higgins, an emergency room official at St. Francis Hospital in Lynwood.