News in brief - Feb. 9, 2004

ED care usually paid on appeal - Ohio hospital yanks privileges - Mass. Blues plan reports heart savings - MedicaLogic founder joins HIMSS

ED care usually paid on appeal

A new study found that most patients who are denied coverage for emergency care by their managed care plans can get reimbursed if they appeal the claim, the American College of Emergency Physicians said.

Researchers from Rand Corp. and the Harvard School of Public Health reviewed 405 appeals of coverage denials for emergency care by privately insured enrollees in two of the nation's largest HMOs, both in California. They found that 90% of the appeals for coverage were won.

The findings were to be published in the February edition of the Annals of Emergency Medicine.

The study also found that disputes over payment for emergency department services accounted for 52% of the post-service appeals received by one plan and 34% for the other. The plans were not identified to protect their confidentiality.

The average cost of a disputed emergency visit was $1,107, according to the study.

Ohio hospital yanks privileges

The dispute over the development of the New Albany Surgical Hospital in Ohio has come to a head for 17 physicians who are losing their privileges at some community hospitals because they invested in the specialty facility.

OhioHealth, a nonprofit hospital chain, said the physicians who were identified as New Albany investors would lose their privileges at its three Columbus-area hospitals as of Jan. 31.

The hospital chain said the move was necessary to follow a resolution that was adopted by its board in October 2002 restricting medical privileges for physicians who invest in competing, for-profit, inpatient hospitals and refer patients there.

Critics have blasted the policy, saying it is tantamount to economic credentialing or granting privileges based on financial reasons rather than qualifications.

The $40 million New Albany hospital, which specializes in orthopedic and neurological services, opened for business on Dec. 1, 2003, after a long dispute over its development.

Mass. Blues plan reports heart savings

BlueCross BlueShield of Massachusetts reported its new care management program for heart failure patients saved an average of $400 per patient per month in 2003.

That translates into an 18% savings in its HMO Blue population and a 21% savings in its Blue Care 65 population, the insurer said. More than 4,500 members are enrolled in the program.

The program, called Cardiac Healthways, offers education and more intensive management services, such as home-monitoring and specialty counseling, to heart failure patients. The savings the program achieves is mostly through reduced inpatient admissions, the insurer said.

The health failure program is one of several disease management programs offered by the insurer. Others include diabetes, multiple sclerosis and rheumatoid arthritis.

MedicaLogic founder joins HIMSS

Mark Leavitt, MD, PhD, who founded electronic medical records software company MedicaLogic Inc., has joined the Healthcare Information and Management Systems Society, a Chicago-based industry group, as medical director and director of ambulatory care.

Dr. Leavitt previously served as vice president of clinical initiatives at GE Medical Systems, which acquired his company, MedicaLogic, in 2002.