WASHINGTON -- As enrollment in health maintenance organizations soars, hospitals across the country report that HMOs are increasingly denying claims for care provided in hospital emergency rooms.
Such denials create obstacles to emergency care for HMO patients or can leave them responsible for thousands of dollars in medical bills.
The denials also frustrate emergency room doctors, who say the HMO practices discourage patients from seeking urgently needed care.
For their part, HMOs -- in which 51 million people are now enrolled -- say their costs would run out of control if they allowed unlimited access to emergency rooms.
Rep. Benjamin L. Cardin, D-Md., said he would soon introduce a bill to help solve these problems. The bill would require HMOs to pay for emergency medical services and would establish a uniform definition of emergency.
The bill would prohibit HMOs from requiring prior authorization for emergency services. A health plan could be fined $10,000 for each violation and $1 million for a pattern of repeated violations.
The American College of Emergency Physicians, which represents more than 15,000 doctors, has been urging Congress to adopt such changes and supports the legislation.
How HMOs handle medical emergencies is a major issue, given recent trends.
Republicans and many Democrats in Congress say they want to increase the use of HMOs because they believe that such prepaid health plans will slow the growth of Medicare and Medicaid.
Under federal law, a hospital must provide "an appropriate medical screening examination" to any patient who requests care in its emergency room and any treatment needed to stabilize the patient.
Dr. Toni A. Mitchell, director of emergency care at Tampa General Hospital in Florida, said: "I am obligated to provide the care, but the HMO is not obligated to pay for it. This is a new type of cost-shifting, a way for HMOs to shift costs to patients, physicians and hospitals."
Most HMOs promise to cover emergency medical services, but there is no standard definition. HMOs can define it narrowly and typically reserve the right to deny payment if they conclude the conditions treated were not emergencies.
The PruCare HMO in the Dallas-Fort Worth area, run by the Prudential Insurance Company of America, promises "rock solid health coverage," but the fine print of its members' handbook says, "Failure to contact the primary care physician prior to emergency treatment may result in a denial of payment."
Hospitals also say HMOs often refuse to pay for their members' care, even if HMO doctors sent the patients to the emergency room. Hospitals then often seek payment from the patient.
Each HMO seems to have its own way of handling emergencies. Large plans like Kaiser Permanente provide a full range of emergency services around the clock at their own clinics and hospitals. Some HMOs have nurses to advise patients over the telephone.
At United Healthcare Corp., which runs 21 HMOs serving 3.9 million people, "It's up to the physician to decide how to provide 24-hour coverage," said Dr. Lee N. Newcomer, chief medical officer of the Minneapolis-based company.
George C. Halvorson, chairman of the Group Health Association of America, a trade group for HMOs, said he was not aware of any problems with emergency care. "This is totally alien to me," said Mr. Halvorson, who is also president of HealthPartners, an HMO in Minneapolis.
About 3.4 million of the nation's 37 million Medicare beneficiaries are in HMOs. Dr. Rodney C. Armstead, director of managed care at the Department of Health and Human Services, said the government had received many complaints about emergency services in such plans.
When HMOs deny claims filed on behalf of Medicare beneficiaries, the patients have a right to appeal. The appeals are heard by a private consulting concern, the Network Design Group of Pittsford, N.Y., which acts as agent for the government.
The appeals total 300 to 400 a month, and David A. Richardson, president of the company, said that a surprisingly large proportion -- about half -- involved disagreements over emergencies or other urgent medical problems.
"In many cases, we rule for the beneficiaries because we determine that the cases are emergencies and the HMOs improperly denied payment," he said.