The Reimbursement Gap

Abstract

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.