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The reimbursement gap: providing and paying for pediatric procedural sedation in the emergency department. 2009

William M McDonnell, and Elisabeth Guenther, and Laurie F Larsen, and Jeff Schunk
Department of Pediatrics, Division of Pediatric Emergency Medicine, University of Utah, PO Box 581289, Salt Lake City, UT 84158, USA. william.mcdonnell@hsc.utah.edu

A number of medical, ethical, and legal obligations compel physicians to provide procedural sedation and analgesia (PSA) to pediatric patients requiring painful procedures in the emergency department (ED). Recognizing the additional demands that PSA places on ED physicians, the American Medical Association has approved Current Procedural Terminology codes for PSA in conjunction with ED procedures. However, some insurers have indicated reluctance or refusal to pay for PSA in the ED, despite these Current Procedural Terminology codes and the legal and ethical imperatives. This reimbursement gap between an obligation to provide care and an inability to obtain reimbursement from insurers places ED physicians who care for children in an awkward position. This article reviews physicians' legal and ethical obligations to provide PSA to pediatric patients in the ED, assesses health insurers' obligations to pay for this procedure, and examines insurers' policies and practices. We found significant variability among private and public insurers in their willingness to pay for PSA. Emergency department PSA charges at one tertiary care pediatric center are reimbursed at less than half the rate of other ED services. Although existing state laws and federal regulations arguably require that insurers provide reimbursement for pediatric PSA, certain legislative and regulatory initiatives could clarify insurers' payment obligations.

UI MeSH Term Description Entries
D002648 Child A person 6 to 12 years of age. An individual 2 to 5 years old is CHILD, PRESCHOOL. Children
D004636 Emergency Service, Hospital Hospital department responsible for the administration and provision of immediate medical or surgical care to the emergency patient. Emergency Outpatient Unit,Emergency Services Utilization,Hospital Emergency Room,Hospital Emergency Service,Hospital Emergency Services Utilization,Accident and Emergency Department,Emergency Departments,Emergency Hospital Service,Emergency Room,Emergency Units,Emergency Ward,Hospital Service Emergency,Service, Hospital Emergency,Department, Emergency,Departments, Emergency,Emergencies, Hospital Service,Emergency Department,Emergency Hospital Services,Emergency Outpatient Units,Emergency Room, Hospital,Emergency Rooms,Emergency Rooms, Hospital,Emergency Services, Hospital,Emergency Unit,Emergency Wards,Emergency, Hospital Service,Hospital Emergency Rooms,Hospital Emergency Services,Hospital Service Emergencies,Hospital Service, Emergency,Hospital Services, Emergency,Outpatient Unit, Emergency,Outpatient Units, Emergency,Room, Emergency,Room, Hospital Emergency,Rooms, Emergency,Rooms, Hospital Emergency,Service Emergencies, Hospital,Service Emergency, Hospital,Service, Emergency Hospital,Services Utilization, Emergency,Services Utilizations, Emergency,Services, Emergency Hospital,Services, Hospital Emergency,Unit, Emergency,Unit, Emergency Outpatient,Units, Emergency,Units, Emergency Outpatient,Utilization, Emergency Services,Ward, Emergency,Wards, Emergency
D006801 Humans Members of the species Homo sapiens. Homo sapiens,Man (Taxonomy),Human,Man, Modern,Modern Man
D014481 United States A country in NORTH AMERICA between CANADA and MEXICO.
D016292 Conscious Sedation A drug-induced depression of consciousness during which patients respond purposefully to verbal commands, either alone or accompanied by light tactile stimulation. No interventions are required to maintain a patent airway. (From: American Society of Anesthesiologists Practice Guidelines) Sedation, Conscious,Sedation, Moderate,Moderate Sedation
D018588 Fee-for-Service Plans Method of charging whereby a physician or other practitioner bills for each encounter or service rendered. In addition to physicians, other health care professionals are reimbursed via this mechanism. Fee-for-service plans contrast with salary, per capita, and prepayment systems, where the payment does not change with the number of services actually used or if none are used. (From Discursive Dictionary of Health Care, 1976) Fee-for-Service, Medical,Reimbursement, Fee-for-Service,Fee for Service,Fees for Service,Fee for Service Plans,Fee for Service, Medical,Fee for Services,Fee-for-Service Plan,Fee-for-Service Reimbursement,Fee-for-Service Reimbursements,Fee-for-Services, Medical,Fees for Services,Medical Fee-for-Service,Medical Fee-for-Services,Plan, Fee-for-Service,Plans, Fee-for-Service,Reimbursement, Fee for Service,Reimbursements, Fee-for-Service,Service, Fee for,Service, Fees for,Services, Fee for,Services, Fees for

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