Q&A: Hospital outside patient insurer's network

Q: If a patient arrives at our emergency department and the hospital's outside their insurer or third-party payer's network, how do we procede?

A: The Emergency Medical Treatment and Active Labor Act requires hospitals to treat and stabilize patients before discussing payment or possibly admission.

Reimbursement requires a call to the patient’s primary insurer or third-party payer to seek directions for care. Many insurers and third-party payers require this within a specific time frame. This is necessary to receive an authorization, directions for follow-up requirements, and directions for sending the patient to a contracted or network provider. Document the call and all details. Once contacted, the hospital will be given:

• An authorization
• Directions for follow-up requirements
• Directions for sending the patient to one of their contracted or network providers (this is referred to as repatriation)

Once directions or an authorization is issued, the call and details must be documented.

Remember that the difference in reimbursement between inpatient and observation is substantial.

Follow-up or concurrent reviews should occur daily. If this is not possible, they should occur at least every third day or as directed by insurers and third-party payers. Use inpatient criteria to review cases involving inpatients transferred from other hospitals regardless of what the admitting orders say.

For more information, see The Hospital Case Management Orientation Manual.

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