Effect of a state definition of an "emergency medical condition" legislation on medicaid managed care organization reimbursement.

Abstract

The state of Michigan passed Public Act 136 of 1997 requiring Medicaid managed care organizations (MMCOs) to pay for emergency services whenever presenting symptoms constituted an "emergency medical condition." The objective of this study was to evaluate MMCO reimbursement before and after enactment of this state law. We conducted a retrospective comparison of reimbursement for lacerations needing repair (identified using Current Procedural Terminology codes from computerized billing data) for 2 time periods (before the state law was applicable [January through March 1998] and after the state law was applicable [April through June 1998]) from MMCO enrollees in 7 different MMCOs presenting to 4 urban emergency departments. Three months after billing submission was allowed for payment. Only refusal of reimbursement was evaluated. Data were analyzed using chi(2) and Fisher's exact test (values of P <.05 were considered significant). The total number of MMCO patients evaluated/total number of ED patients evaluated for the 2 periods was 1,769/32,646 and 3, 376/30,901, respectively (P <.05). The number of MMCO lacerations with no reimbursement/total number of MMCO lacerations for the 2 periods was 4/135 (3%) and 78/196 (40%), respectively (P <.001). Reimbursement by MMCOs for a procedure chosen to reflect a state-defined "emergency medical condition" is inadequate and significantly decreased during the 2 periods, with a significant increase in MMCO patients evaluated.