new to rural

[MAMed]

I am a medic who works full time in an urban area and cut my teeth on that. I recently started part time for a service that covers rural counties and have a question about recent experiences. Last night I got a call to the local band-aid station to transfer a stable OB pt. The on site doc wanted me to go where the pt doc was rather than the closest appropriate facility. I explained to the pt that insurance would not pay the extra milage and the pt chose to go POV. The on site doc proceeded to lie about the other hospital's capabilities (maybe he was just ignorant, I don't know) and chewed me out in the ER. I have had similar experiences in another county where I picked up a PRN shift. Is this sort of thing common in rural areas, or am I just a sh** magnet and this kind of thing follows me around?

BTW: The doc's diagnosis was questionable because it was a supposed pre-eclamptic pt who was normotensive.

[spenac]

Welcome to fraud 101. Sadly many Doctors will regardless of where they are make false statements on the forms in order to make patient happy. Just document your findings even though they contridict the doctors.

Rural EMS is much more fun and challenging. That is if you are really rural. You have to use your education, you see the results of your actions, where in the city even if you treat most of the time your already at the ER prior to seeing the result.

[Just Plain Ruff]

I find some problems with this scenario and please do not take this as a personal attack but I'm surprised to say the least.

The patient had an accepting physician at the receiving hospital and you talked her into a refusal based on that insurance would not pay?

You also talked a pre-eclamptic patient into a refusal based on insurance reasons?

I would request that you run this one by your risk management people at your service to see if that was the right thing to do.

What is your level of medical education that gives you the ability to say she was not pre-eclamptic? What was her blood pressure? If her pressure was 140/90 then she's pre-eclamptic. Remember that pre-eclampsia can also be diagnosed with the absence of high blood pressure but there is the presence of protein in their urine.

Did you see the Urinalysis? If not then you dont' really have all the tools to dispute the diagnosis of pre-eclampsia do you?

I am still shocked that you would get a refusal based on insurance reasons. Are you sure her insurance policy would not cover the charge for the extra mileage?

I think you should re-think how you handled this case.

For your edification here is what can happen to the baby if pre-eclampsia is left untreated

How Can Preeclampsia Affect My Baby?

Preeclampsia can prevent the placenta from receiving enough blood, which can cause your baby to be born very small. It is also one of the leading causes of premature births and the difficulties that can accompany them, including learning disabilities, epilepsy, cerebral palsy, and hearing and vision problems. (Source http://www.webmd.com/baby/guide/preeclampsia-eclampsia

Here is another resource that you can refer to. It's from the Mayo Clinic

http://www.mayoclinic.com/health/preeclampsia/DS00583

[Dustdevil]

Unless there were some critical medical implications that you haven't mentioned to us, I don't see the problem. I'm a medic, not a billing manager or system status manager. They get paid more. You call, I haul. Unless my patient's life is threatened by your choice of destination, I'm going where you (the physician) want me to go. Why wouldn't I? I just don't understand why you care. Were you in a hurry to get back to your recliner, or what? That's an urban attitude that will become a problem for you in rural practice, I assure you. I know I had to adjust my attitude when I went rural the first time. You (anybody going rural) have to chill out with all the Mr. Public Safety "I'm in charge" stuff and just serve your people.

And no, I am not telling you what to think. I'm just asking if there is more information to this scenario because, regardless what you thought at the time of posting, this isn't a very complete scenario for us to evaluate.

[MAMed]

I'm sorry let me clarify. I did not get a refusal. I told her that I would be happy to transport her but I am legally bound here to inform a transfer pt is there is a possibility that insurance will not pay part or all of the trip (in this case only the milage to the closest facility). The pt refused on her own. This came up because the on site doc told her that the closest hospital did not have OB. My supervisor checked with that hospital who said they did and would be happy to take her. The issue was not wether to transport but closest apporpirate facility. This would also take an ambulance out of service for extra time when there are only two in the county.

[MAMed]

Let me explain some of the local legal background to clarify any misunderstandings about the situation. In the state of MS for a pt to have insurance pay for a non-emergent transfer the hospital sending out the transfer must provide a standard state form that gives a reason why the transfer is medically necessary. All emergency transfers must go to the closest appropriate facility. Any stable A/O pt must be informed by the paramedic if there is a possibility that insurance will not pay. At that point the pt can still be transported if they sign a concent form stating that they have been told this.

The pt mentioned above was informed in the manner mentioned and was told her options about transport to the closest hospital. At that point, she refused to go by ambulance without any coercion.

While I might not have all the details of the above laws that is the general basics of them as far as I have to know them. I might not like the rules but I have to play by them.

Another background note is that the hospital in question above is an extension of the state university medical center and regularly send pts to the main branch simply so they don't have to deal with the pt regardless of medical necessity of transport.

[Chief1C]

The last thing that I talk to the patient about, is how much it will cost. I don't see the money, I let the billing agency worry about that. If they're stable enough to get where they need to go, I don't take them to a place that I feel is good enough. Not all hospitals are created equal, some are just better, plain and simple.

[Dustdevil]

I'm still curious as to why you give even a cursory glance at the billing implications of your runs. Is there a written agency policy directing you to biopsy these people's wallets? Was this something you spent a week on in paramedic school? Or is this just something you have taken upon yourself to do?

Yes, I know there are some private companies out there -- usually non-ems -- that ask their employees to focus on these sorts of things, but I would seriously doubt that your new rural county agency does. If not, you're going out of your way to make trouble for yourself and your patients. Let it go.

[reaper]

I agree with Dust. You are not the billing manager. Unless you talk to the ins. company personally, You do not know that it will not pay the cost. If the Dr. has the form filled out, then he has covered his bases. The closest hospital may have a OB ward, but how good is it? Most rural hospitals don't deal in OB that often. The DR. may have wanted her to go to the better Hospital for treatment. That is his decision, He's the DR.!

How can your state tell you that this pt is non-emergent? If she is pre-eclamptic, She could go down hill at any time. I don't see the state examining the pt, before transfer. I would not put my lic. on the line, because of a Insurance law.

It is all your decision, but rural EMS is about the pt, not money. God knows there's no money in it!

[Just Plain Ruff]

The thing is if this was a emergent transfer which pre-eclampsia could be(should be considered a emergent transfer) then I think insurance would cover the transfer.

telling a patient that insurance will not cover a particular part of a run, especially one that is from one hospital to another is tantamount to forcing a refusal.

You say that you did not coerce a refusal but I contend that you did. The reason why I contend you coerced a refusal is in what you said. You told her that insurance would likely not cover the mileage to the other hospital and you also said that it kept both your ambulances in your county available with the refusal.

You can say that she was the one who initiated the refusal but I believe that since you mentioned the insurance issue to her that you initiated the refusal and she felt coerced into signing the refusal based partly on you telling her insurance would not have covered the extra miles.

I can say that I've had to discuss insurance issues with patients but never on a transfer from a hospital to another hospital.

I'm curious as to what the ER physician said to you when you got the refusal? I can't imagine it was not a happy talk.

Did you ever go to your risk management people and ask them what they thought of you getting a refusal on this patient?