Effect of state legislation prohibiting denial of emergency department patient claims

Study objective: On July 1, 1996, two Florida state laws were implemented t o prevent denial of legitimate patient claims. Our objective was to determi ne whether the laws have been effective in reducing inappropriate denials a s measured by the proportion of claims and charges denied. Methods: A comprehensive set of claims for in-state emergency physician ser vices from a physician billing company were analyzed for the period January 1996 through June 1997, covering 6 months before and 12 months after the e ffective date of state legislation. The number of facilities included in th e data varied from 55 to 67 (mean 63). Denials were classified into 6 categ ories by payer type. Gross denials were those claims that were completely n ot paid by the payer, net denials represented the amount denied after patie nt payments. Downcoding was not examined in this study. Main outcome measur es were the proportion of claims and charges denied before and after July 1 , 1996, Results: The classification of relative proportions of primary payers did n ot change appreciably over the study period. The proportion of denied claim s decreased significantly (Kruskal-Wallis P<.001), starting 2 months after implementation. Conclusion: After initiation of slate legislation, payers continue to inapp ropriately deny claims, although the number of claims and total charges den ied has decreased. In response to this legislation, payers are denying larg er claims and patient copayments have increased.