Insurance denials of EMTALA claims?

by R
(Ontario, California)

We have several emergency claims that are denied on a regular basis by Aetna, Blue Cross, Blue Shield, United Healthcare, Care 1st (to name a few). The insurers constantly deny payment due to "No Authorization for Treatment" or "Non Medical Necessity," or they process it to the patient's deductible and expect us to write off the rest.

This happens with Contracted and Non-contracted insurance payers. I've read EMTALA over and over but, I can't find the actual wording that states, if it is found that the patient has medical insurance after the emergency treatment has already been rendered, then the patient's primary health care insurance can be billed and has to pay for the emergency treatment provided.

Is this stated? There must be a provision that requires insurers to pay for emergency medical treatment. Do you have any information regarding this? Thanks for any information you can give.

Visitor Question:
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ANSWER for "Insurance denials of EMTALA claims?":

R (Ontario, California):

Your questions suggests you are inquiring as an employee or physician in a medical facility.

The Emergency Medical Treatment and Labor Act (EMTALA) was enacted by Congress in 1986. The Act requires hospitals and other medical facilities who receive Medicare payments from the U.S Government to provide emergency medical treatment to anyone needing such treatment regardless of citizenship, legal status, or ability to pay.

There are no reimbursement provisions.

Hospitals who fall under the Act may not transfer or discharge patients needing emergemcy medical treatment, unless the patient consents in writing to being discharged, so he or she can be transferred to a medical facility better suited to deal with a specific injury and its treatment.

The key words in the Act which apply to your question are, "There are no reimbursement provisions." This language means the Government, and the patient's insurance companies, are NOT required to reimburse you for the medical care your facility rendered.

The above is general information. Laws change frequently, and across jurisdictions. You should get a personalized case evaluation from an attorney licensed in your state. Find a local attorney to give you a free case review here, or call (888) 647-2490.

Best of luck,

Judge Calisi

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