Dr. Ralph Northam

Governor

Commonwealth of Virginia

PO Box 1475

Richmond, VA  

Governor Northam, 

            Emergency Physicians of Tidewater is a partnership of over 150 Emergency Medicine physicians and Advanced Practice Providers serving the South Hampton Roads communities.  We staff the Emergency Departments at Sentara Norfolk General, Sentara Leigh, Sentara Virginia Beach General, Sentara Princess Anne, Sentara Obici, Sentara Independence and Sentara Belle Harbour.  As an employee of this group, I am reaching out to you today to oppose the ER Utilization reduction in Medicaid reimbursement that is contained in the Commonwealth’s biennial budget.  

            We are proud to be able to serve the most vulnerable in our communities; we play a significant role in the safety net for this population.  During the pandemic, our group remained fully staffed and on duty, at the risk of our and our families’ wellbeing, and despite the negative financial impact to our practice.  Our financial recovery, and the recovery of the entire healthcare system that serves Medicaid recipients, will be challenged unless this budget is amended.    

            As a physician, you well understand the importance of providing emergency care without regard to coding or payment issues.  I urge you to draw on your experience as a physician to guide you when considering the impact of this budget action on the Medicaid recipients, and on the stability of the healthcare providers that they depend on. 

While the proposed legislation offers cost reduction for a strained budget, similar legislation passed and later reversed in Kansas did not meet the Prudent Layperson standard, as referenced in a CMS Final 2016 Medicaid Managed Care Rule:

            Regarding the PLP requirements of the BBA of 1997 and the use of approved lists of emergency diagnosis codes, we remind commenters that consistent with our discussion in the 2002 managed care final rule at 67 FR 41028–41031, we prohibit the use of codes (either symptoms or final diagnosis) for denying claims because we believe there is no way a list can capture every scenario that could indicate an emergency medical condition under the BBA provisions. ... While this [PLP] standard encompasses clinical emergencies, it also clearly requires managed care plans and states to base coverage decisions for emergency services on the apparent severity of the symptoms at the time of presentation, and to cover examinations when the presenting symptoms are of sufficient severity to constitute an emergency medical condition in the judgment of a prudent layperson. The final determination of coverage and payment must be made taking into account the presenting symptoms rather than the final diagnosis. The purpose of this rule is to ensure that enrollees have unfettered access to health care for emergency medical conditions, and that providers of emergency services receive payment for those claims meeting that definition without having to navigate through unreasonable administrative burdens.¹

             My colleagues and I feel strongly that this item in the budget should be eliminated.  We ask that you consider alternative cuts that do not pose such a risk to the dedicated Emergency Medicine providers and systems that often serve as primary providers to this population in Virginia.     

Sincerely,

Barry J. Knapp, M.D.