Denial of authorization to pediatric managed‐care patients at an urban emergency department

Objective To assess whether some pediatric Health Maintenance Organization (HMO) patients denied authorization for payment of emergency department (ED) services do not meet established nonemergent triage criteria and thus might be at risk for poor outcomes. Design A consecutive case surveillance. Setting and participants A Chicago inner city university-based ED with a total patient volume of 42 000 patient visits per year, of which 30% are pediatric. Managed care is approximately 20%. Participants who were denied authorization for payment of ED services by their HMO were age 0–16 and subsequently left the ED without treatment. Variables studied Data were collected from the ED nurse's triage notes. Chief complaint, vital signs, and focused examination were used to categorize patients as emergent, urgent, or nonemergent based on previously published pediatric emergency department triage criteria. Results A total of 83 pediatric HMO patients between 0 and 16 years of age were denied authorization for payment of ED services and subsequently left the ED without treatment in the study period. Of these, only eight patients (9.6%) met criteria to be categorized as nonemergent, and 75 (90.4%) met criteria to be categorized as emergent or urgent. Of these 75 patients, 17 (22.7%) had abnormal vital signs as the sole criteria for the emergent/urgent categorization, 16 (21.3%) had chief complaints considered emergent, and 42 (56.0%) had chief complaints considered urgent. One patient was not categorized into either group because he had left the ED before his HMO's authorization decision was rendered. Conclusion The results suggest that many of our pediatric HMO patients denied payment for ED services are being placed at risk for poor outcomes. The results highlight the haphazard nature of telephone authorization by HMOs and question the safety of this triage practice. The patients who are denied authorization for payment of ED services and subsequently leave the ED need to be further studied to determine their ultimate outcomes.