http://www.hhs.gov/progorg/oig/modcomp/cpgm.htm

THE OFFICE OF INSPECTOR GENERAL'S
DRAFT COMPLIANCE PROGRAM GUIDANCE
FOR MEDICARE+CHOICE ORGANIZATIONS 
OFFERING COORDINATED CARE PLANS

JUNE 1999

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g. Anti-dumping

The OIG and HCFA believe that there may be special concerns regarding the
provision of emergency services to enrollees of Medicare+Choice plans. The
anti-dumping statute(71) imposes specific obligations on Medicare-participating
hospitals that offer emergency services to individuals presenting themselves at
the hospital seeking possible emergency treatment. While the obligations under
the anti-dumping statute prohibit a hospital from inquiring into the patient's
method of payment or insurance status, it has come to our attention that many
hospitals routinely seek authorization from a Medicare+Choice enrollee's
primary care physician or from the Medicare+Choice organization when a
Medicare+Choice enrollee requests emergency services. The OIG and HCFA are
cognizant that many managed care organizations require their enrollees to seek
prior authorization for some medical services, including emergency services and
that there are circumstances when patients should be informed of their
potential financial liability. However, both the OIG and HCFA have concerns
that a Medicare+Choice enrollee may be unduly influenced by hospital personnel
to leave the hospital without obtaining necessary care.(72)

It is the view of OIG and HCFA that the anti-dumping statute requires that
notwithstanding the terms of any managed care contractual arrangements, the
provisions of the anti-dumping statute govern the obligations of hospitals to
screen and provide stabilizing treatment to any patient presenting at an
emergency facility. No contract between a hospital and managed care
organization can excuse the hospital from the anti-dumping statute obligations.
Once a Medicare+Choice enrollee comes to the hospital that offers emergency
services, the law requires that the hospital must provide the services required
under the anti-dumping statute without regard to the patient's insurance status
or any prior authorization of such insurance. All Medicare+Choice organizations
should have policies in place to ensure that these requirements are met.

Medicare+Choice organizations should be particularly careful of these
requirements in the event that they participate in the so-called "dual
staffing" of emergency departments. Dual staffing refers to the situation where
hospitals have entered into arrangements allowing a managed care organization
to station its own physicians in the hospital's emergency department for the
purpose of screening and treating managed care enrollees. Implementation of
dual staffing raises some concerns under the anti-dumping statute, particularly
where different procedures and protocols have been established for each staff. 

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71. See 42 U.S.C. § 1395dd. A separate provision prohibits Medicare+Choice organizations
requiring enrollees to obtain prior authorization for emergency services. See 
42 U.S.C. § 1395w-22(d)(1)(E). 

72. OIG and HCFA have issued a proposed Special Advisory Bulletin on this topic. 
See 63 Fed. Reg. 67,486 (12/7/98).