Sunday, October 12, 2014

The Empire Strikes Back: I Was An EMTALA Victim Due To An Exclusive Provider Contract

By Scot Sturtevant, EMT-P, BBA, ACHE

The other day, I got a text message from my sister that my father was being sent to the hospital for a fall, and that he was disoriented and she wasn’t sure how long he’d been on the ground.  So she called 911, and the fire EMS team came to her home and took dad to the hospital.

My father’s health had long been on the downslide, ever since my mother took ill 10-years ago and passed away very suddenly.

Dad was lost without her by his side. They had been married well over 50 years, and when you’re married for that length of time, the loss can be devastating to say the least. Dad and Mom had moved from Pahrump, Nevada to Albuquerque, New Mexico, to be closer to my baby sister, who had invited them there, to care for them as they aged. 

Somewhere in the midst of all the moving and upheaval, Dad got sick with pneumonia, taking a toll on his lung functions. Dad had been diagnosed with COPD many years earlier due to his cigarette smoking.. So when the pneumonia set in, dad found himself on oxygen by nasal cannula...  for the remaining years of his life.

In his youth, my father was a non-degreed engineer. When Dad graduated from high school he joined the Navy, serving in the Korean conflict. Immediately after his discharge in 1956, he went to the state’s licensing board downtown and took the his California State Mechanical Engineer licensing exam, providing him a license as a “non-degreed” Mechanical Engineer. Need less to say that it’s not a very easy feat, back then, but to be honest, Dad had a higher than normal IQ, and was a extraordinarily fast learner.

Dad took a job at General Dynamics’ Kearney Mesa facility, where he thrived as a part of the design engineering team that developed much of the technology that was used in the space race of the 1960’s He also was a math wizard like you’ve never seen, solving complex equations in his head, never touching a “slide ruler” or calculator to help him. He was like “Superman” to me as I grow up, and taught me many, many things that I still carry with me today.

When my father arrived at the hospital, he was admitted to the floor following his brief stint in the emergency room, where he fell asleep under the watchful eye of my sisters and the nursing team. All was well and he was content.

They following morning, I went up to visit him and see how he was doing. I spoke with his nurse who gave me the entire history of his stay at the hospital, including the treatment he’d undergone, and the things that they’d found. I was very happy to see that although he’d broken a rib, he’d not developed another case of pneumonia.

For what had been done and considering what had taken place, I was pretty happy with his treatment and had no complaints. I knew Dad was going to be transferred to a rehab facility to get him back on his feet, so I requested that the nurse inform his case manager that I wanted him to be transported by the company I had been doing some work for, rather than the company that the hospital was contracted with. It was a reasonable request to say the least. It happens all of the time, and well within my right as one of his caretakers and as his son. This would allow us to control cost issues and afford him a reasonable rate for the service, and a hassle-free situation, should we find it necessary to file hardship paperwork considering his financial state.  I’ve had many people who have come to me in the past to help them file this sort of paperwork, and this particular company had always made it a difficult and protracted process to accomplish. By using a different vendor, I could avoid such a headache.

I spoke with the nurse caring for my father, who was very kind and understanding, and noted the request in my father’s chart and on the whiteboard inside his room. She assured me that there was no way the case manager would miss this obvious request.  I left the hospital with the confidence of knowing that my father was in good hands and that all of our wishes as to his care and treatment were taken care of and notated. But I was about to be the victim of a "back room bargain" that I had not been aware of, and had no idea was a part of the contractual arrangement between the ambulance company that held the exclusive contract with the hospital, and the policy that was drafted by the hospital to assure that staff wasn’t calling anyone else.

The following day, my father was discharged from the hospital to the rehab facility. So, I contacted my sister to make certain that everything went off without a hitch and that Dad had a good trip. I also inquired about the transport by the agency I had requested.

As I’m sure you can guess, everything had gone on without a hitch, except one thing, the trip by the ambulance company. Instead of the company that I had chosen, the company the hospital was contracted with took my father to the rehab facility. I was incensed!

I began to act more like an inquisitor than a brother. My sisters had been trying to control the cost out of pocket of his care, and this company he had been taken by had a long-standing history of violating contractual arrangements with health plans and payors. In fact, I had gotten into an accident several months before, and had requested transport to a non-trauma facility in the other direction. My request was ignored, and against my request and wishes, was transported to the more expensive trauma center, although there was only a laceration that needed suturing, and no trauma or loss of consciousness.

The company in question shall remain nameless. But to say the very least, this company has had a history of questionable billing and business practices. In fact, the company had been under the watchful eye of the Federal Medicare Administration via a “Corporate Compliance Agreement” since at least 2006. The company also had recently emerged from a reorganizational bankruptcy as well.

As far as my father’s situation goes, my sisters informed me that they weren’t given a choice in the matter. They had expressed to the case manager in charge of his case the request for a different vendor, but the case manager argued the point with them telling them that they had to use the contacted ambulance provider or his bill would be uncovered and they’d be responsible for the transport. So they felt their back was against the wall, and took her word for it, allowing her to use their contracted provider.

From my perspective, I find the actions of the hospital case manager to be reprehensible. Upon speaking to the Director of the hospital’s case management department, I was showered with platitudes and apologies for the oversight. However, I decided that enough was enough.

Most hospitals in Southern California are under contracts with providers to handle their diagnostically related transports for treatment, in an effort to contain costs. Under the PPS system, this practice is allowed, even discounting in such situations is allowed as long as the discount is included as a part of the agreement, prior to its implementation and subsequent execution, as long as the discount is reported on the hospital’s costing report to Medicare. Similar arrangements may be discounted too under managed care agreements where the discounting is protected by Federal “safe harbor” regulations, provided that the discount amount is not part of a larger inducement or “discount swapping” arrangement.

In my father’s case, yes it was a Medicare transport. However, it was a Medicare Part-B transport, not a Medicare Part-A transport. My Dad was being discharged to a rehab or skilled care facility, he needed oxygen at all times, and it had to be monitored due to the respiratory instability of his condition.  Therefore, “medical necessity” was met for the transport. Second, it was a part-B transport (fee-for-service), rather than a Part-A (Bundled as a part of the hospital billing to Medicare) transport, because he was being discharged into the care of a step-down facility, and not as a part of a continued treatment that was to be provided by the hospital.

My problem with all of this was straightforward and simple. It was clearly an EMTALA violation by disregarding the request and wishes of the patient or their family to determine a course of care for a patient. This right, as handed down by the government, lies not with the caregiver. Now my family was able to see firsthand the problem I’ve seen with those who tend to tell lies to the public on what is and is not covered as a part of the care and service offered in a hospital.

Since my time in EMS and now as a consultant, these types of transports by an ambulance company have been and still are covered by Medicare Part-B. I’ve been in this industry since 1977, and nothing has changed in this regard transporting a patient who met the medical necessity qualifications, from receiving the benefit of coverage for an ambulance transport. So why would the hospital’s case managers be believing differently, or telling my sisters something that wasn’t true?

The answer to me is somewhat obvious....
  • ·        Lying (by someone somewhere)
  •        An absolute lack of training or competent hiring practices of qualified people to make those determinations. 
  •      A “back room” deal (quid-pro-quo) where both parties agree to "swap discounts" in an effort to maximize the discount the hospital receives from the ambulance company, and the Medicare referrals the ambulance company receives from the hospital.

·       ... And the band played on.

The other day, I read an article online about the Medicare program’s eventual insolvency that looms on the horizon. 

I wondered silently what they’re all going to do when in a few short years, when its all gone... dried up and blown away like dust in the wind. 

I leaned back against my chair at my desk, and as horrible as it may sound, I had a brief moment where I felt a sense of resignation, wondering why I fight at all.

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