THE IMPACT OF HEALTH MAINTENANCE ORGANIZATION CARE AUTHORIZATION POLICY ON AN EMERGENCY DEPARTMENT BEFORE CALIFORNIA NEW MANAGED CARE LAW

Objective: To examine the effect on patient care of HMO-mandated calls for authorization prior to ED evaluation. The study examined this phe nomenon prior to implementation of a California law that discourages s uch calls. Methods: Concurrent data were collected for patients who pr esented to the ED and who had authorization calls made to their HMOs p rior to their ED evaluations during the period September through Decem ber 1994, Data collected included: 1) the number of authorization call s made, 2) the frequency that ED care was deemed unnecessary by the HM O, 3) the outcomes of patients denied authorization, and 4) the time a nd personnel involved in completing calls. Follow-up phone calls were made to patients who left the ED after the HMO denied authorization fo r payment. Results: The total ED census was 19,935 patient visits for the four-month period. Authorization calls were made for 4,642 (23%) o f the ED visits. There were 545 patients (12%) in this group who had a uthorization denied and only 29 (5%) chose to remain in the ED for con tinued evaluation. The total time required to complete a call ranged f rom 20 minutes to 2.6 hours. Authorization calls and denials caused th e following problems: 1) patients for whom calls were made were subjec t to delays in ED care; 2) at least seven patients referred to HMO cli nics 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 con ditions; and 4) high-risk patients denied authorization included patie nts with final diagnoses of ectopic pregnancy, acute myocardial infarc tion, pulmonary embolus, respiratory failure, and sepsis. Conclusions: Calls for payment authorization prior to ED patient evaluation delay patient care and place some patients' health and safety in jeopardy.