pEND Action Center

Click Here For A Short Presentation Offering Clear and Concise Explanation On PEND and Medicaid MCO Payment Reductions. 
Presentation Author: VACEP President, Jake O'Shea, MD, FACEP

ACTION ALERT!!
October 2013

Dear Colleagues- 

We have spoken to many this year about the importance of eliminating the DMAS PEND program, which unfairly reduces payments to emergency physicians.     Our key effort this year is to have the Governor's budget include elimination of PEND, and so far we are on the right track... but we are at a critical juncture and need your help.

Please review the following message, crafted by our government services team,  and ACT IMMEDIATELY.  We need to speak loudly and together on this issue.  If you only participate in one legislative effort this year - this is the time that we need your help.  It only takes 1 minute of your time.

Thank you all for your help - again, please do this today.

--Jake O'Shea, MD, FACEP
President, Virginia College of Emergency Physicians

 

Below are three example emails for you to use when crafting a message to Governor McDonnell.  Please add your own examples of cases you've seen that were not paid fully because of PEND.

WHAT: Email the Governor and ask for PEND elimination to be included in the 2014-2016 budget; Pass the alert on to your colleagues and ask them to contact the Governor too. 

WHEN: Immediately - the deadline is October 20th, but please do this as soon as you read this message.

HOW: Log on to the Governor's website here- http://www.governor.virginia.gov/AboutTheGovernor/contactGovernor.cfm 

Complete the Sender Information. 

Then in Message Information copy and paste one of the options below (be sure to fill in highlighted parts appropriately).  Or if you prefer, send your own personalized message.

OPTION MESSAGE 1 

Message Subject:
Please Eliminate the ER PEND Program in Your Budget

Message Body:
Dear Governor McDonnell:

As an emergency physician practicing in Virginia (insert years practicing here), I am writing to respectfully urge you to include the elimination of the administrative DMAS PEND program in your final budget.

As a member of the healthcare safety net, the PEND program penalizes my colleagues and me for treating Medicaid patients- even though we are required by federal law to see all patients who come through the door. By pending, reviewing and then cutting our payments in half, the PEND program treats us differently than every other group of physicians. Eliminating the PEND program in your final budget is a simple fix- with a general fund cost of approximately $430,000.

This elimination is critical for physicians as we continue to provide services to Virginia's safety net population 24 hours a day, seven days a week, 365 days a year. Thank you for your attention to this important matter.

Sincerely,

(Insert your name and degree),

(Insert your title and hospital here)

OPTION MESSAGE 2

Message Subject:
Please Eliminate the ER PEND Program in Your Budget

Message Body:
Dear Governor McDonnell:

As an emergency physician practicing in Virginia, I am writing to respectfully urge you to eliminate the administrative DMAS PEND program in your final budget.

The PEND program treats emergency physicians differently than any other specialty by pending, reviewing and then cutting payments in half from $42.00 to $22.06 for many Level III claims. Level III claims represent almost half the visits seen per year in emergency departments.  An example of such a claim is an 18-month-old child who presents with a 105-degree fever and the physician needs to determine if this is a serious case of bacterial pneumonia or a simple viral cold.  (Insert your own example here)

The elimination of PEND is not complicated- please amend the budget to eliminate the policy of PEND in DMAS and then allocate the necessary funds of approximately $430,000. This is a critical need for those of us providing services to Virginia's safety net population. Thank you for your attention to this important matter.

Sincerely,

(Insert your name and degree),

(Insert your title and hospital here)

 

OPTION MESSAGE 3

Message Subject:
Please Eliminate the ER PEND Program in Your Budget

Message Body:
Dear Governor McDonnell:

As an emergency physician practicing in Virginia (insert years practicing here), I am writing to respectfully urge you to include the elimination of the administrative DMAS PEND program in your final budget.

While I understand that you are faced with many decisions within the HHR budget that includes numerous worthy programs and initiatives, I believe the elimination of PEND must be a top priority.

The DMAS PEND program illogically pends, reviews and then cuts physician payments for level III cases in half from $43.00 to $22.06 after we have already provided services. The cases we see in these instances are some of the more difficult ones because when they present to us, the patient's symptoms require an intensive work up.  And with the potential increase of patients in our emergency departments in the near future, I am genuinely concerned we will not be able to afford to hire enough physicians to handle this influx of patients. 

As an emergency physician, I am required by the Federal EMTALA law to take care of all of my patients- regardless of their ability to pay. When EMTALA and PEND intersect, Virginia is essentially refusing to fully compensate us for taking care of our patients.

The elimination of PEND is not complicated- please amend the budget to eliminate the outdated policy of PEND in DMAS and then allocate the necessary funds of approximately $430,000.

Thank you for your attention to this important matter.

Sincerely,

(Insert your name and degree),

(Insert your title and hospital here)


What is PEND? 

For years, the PEND program has been used by the Virginia Department of Medical Assistance Services (DMAS) to reduce payments to EPs who care for fee-for-service Medicaid patients.  PEND is short for "PEND, review, and reduce."  Briefly, the process pends payment on provider claims, requires submission of additional documentation for review, and then reduces payment to $22.06 on all claims deemed to be "non-emergent" in nature;  this process falls outsdie of the Virginia prudent layperson standard, which applies only to managed care organizations. The PEND program was instituted years ago - before EMTALA!  It originally had the misguided intent of decreasing ED utilization by Medicaid patients, but ultimately has succeeded only in unfairly decreasing payments to EPs.

VACEP has vigorously fought to eliminate the PEND program.  Several years ago, we negotiated with Pat Finnerty (former DMAS administrator) to eliminate PEND for all E&M codes except 99283.  At that time, Mr. Finnerty advised us that completely eliminating the program would require changes in the DMAS budget; the cost of PEND elimination at that time was approximately $2 million.  Since that time, as more Medicaid patients have been shifted to Medicaid Managed Care Organizations (MCOs) – which historically did not PEND ED Charges -  the cost of PEND has decreased to approximately $430,000, but complete elimination still requires budgetary action.  VACEP has tried to eliminate PEND via amendments to the state budget each of the past two years, but unfortunately those efforts have not been successful.  This year, however, the stakes are much higher.

That is because the Medicaid Managed Care Organizations have begun to employ a process similar to PEND, called “Reduction to ER Triage Fees.” A Medicaid MCO is typically a subsidiary of a large health plan (e.g. Anthem).  DMAS pays the MCO a flat fee per member per month, and the MCO then uses this money to pay for the care of its Medicaid members; anything left over is profit to the health plan.  In 2012, 66% of Virginia Medicaid patients were MCO members.

In 2012, two MCOs (VA Premier and Anthem Healthkeepers Plus) began performing what they called a “prudent layperson review” for ED claims of all levels (1-5); ironically, a medical director may often perform this review.  If that review finds that a visit is “non-emergent”, the MCO pays a drastically reduced fee ($22), which the MCOs claim covers the “Medical Screening Exam” at a rate similar to that paid to a PCP for a brief office visit for a new patient.  Arguments to the MCOs that the Medical Screening Exam may, in fact, require multiple complicated tests and a prolonged stay in the ED have not been successful.  These payment decreases are NOT anticipated by DMAS as part of the fee paid to the MCOs, and ultimately represent additional profit to the health plans.  If these reductions to ER fees continue to expand, they represent an even greater loss to EPs than does the fee-for-service PEND program.

EPs absolutely deserve to get paid for the services we provide, and both of these programs are inherently unfair.  If a cardiologist performs a heart catheterization but finds clean coronary arteries, he is still paid for the time and effort required by the procedure; similarly, EPs deserve to be paid fairly for the diagnostic evaluations we perform on our patients – even if we ultimately diagnose that a presenting complaint (e.g. chest pain) is due to a condition that does not require emergency treatment or admission (e.g. GERD).  ED physicians deserve to get paid fairly – but unless we speak loudly, and with one voice, we will continue to face unfair payment reductions for care of Medicaid patients. 

WHAT HAS VACEP BEEN DOING? 

2013:  This year, our efforts to eliminate PEND and the MCO decreases must be successful.    We have strong allies – including:  the MSV (who has voted elimination of PEND as a top legislative priority); Secretary Hazel; Cyndi Jones, the head of DMAS; VA AAEM and many legislators.  Instead of a legislative budget amendment for 2014, our goal is to have PEND elimination included in Governor McDonnell’s budget, at the request of Secretary Hazel.  Once that occurs, we believe DMAS can direct the MCOs to stop reducing payments to “ER triage fees” via the Medallion II, a directive they are unwilling to give while the PEND program remains on the books for DMAS.  Now, we need your help.  In order to convince the Governor to include PEND elimination in his budget, we will need letters from as many ED physicians as possible to both Secretary Hazel and the Governor.  VACEP will supply you the bullet points, which you can use to craft your own letter; form letters will not fit the bill, unfortunately.  When we send the bullet points, we will also explain exactly how to submit these letters electronically.