Hospital Refuses to Treat Patient Until Insurance Can be Verified

Peachford Behavioral Health System (PBHS) of Atlanta was cited by the Centers for Medicare and Medicaid Services (CMS) for noncompliance with the “Special Responsibilities of Medicare Participating Hospitals in Emergency Cases.” Specifically, the facility was cited for delaying a patient’s examination or treatment in order to seek additional information on the patient’s insurance/payor source, and refusing to accept the patient even when it had the specialized capabilities and capacity to treat his/her emergent psychiatric condition.

The cited deficiencies relate to an incident in which a patient was referred to PBHS after ER personnel at the transferring hospital determined the patient needed to be involuntarily committed for inpatient psychiatric care after he/she exhibited homicidal ideations and threatened to kill his/her family. However, the transferring facility’s nurse noted that she received two calls from two different PBHS staff members stating that the patient had been declined due to insurance issues. The patient’s Medicaid insurance was through Peachcare for Kids, but PBHS only accepted Peachcare coverage through Amerigroup and Peach State. The patient was eventually transferred to another psychiatric facility in stable condition, even though the patient’s mother requested that the patient be transferred to PBHS.  An interview with the PBHS Director of Referral Services revealed that the patient’s payor source needed to be known in order to assign a physician who accepted the patient’s payment source and determine which medications and treatments could be ordered.