Financial Implications for Physicians Accepting Higher Level of Care Transfers

Mark I. Langdorf, MD, MHPE; Sharon Lee, MD; Michael D. Menchine, MD, MPH


Western J Emerg Med. 2013;14(3):227-232. 

In This Article


The study used the same group of 570 HLOC patients to examine professional reimbursement as the previous study, which looked at hospital reimbursement.[7]

We identified all transferred patients (regardless of HLOC status) from 3 different sources. First, the county government Emergency Medical Services Agency maintains an Interfacility transfer (IFT) report with patients who were initially seen at a primary paramedic receiving center ED, but then sent immediately with the same ambulance to a designated specialty center (n=90 patients). Second, this hospital's transfer center maintains a log of phone requests for transfer into this tertiary care facility (n=457 patients). We verified that patients on the IFT list came to this tertiary ED via this hospital's electronic medical record and this log book. Finally, we queried the ED tracking board at this tertiary care hospital to identify referrals for HLOC that came directly to the EP, rather than the transfer center (n=185 patients). Duplicates were identified and removed from the list, resulting in 570 patients. Of these, 319 (55.9%) were transferred to this tertiary center through the ED, while 251 (44.0%) came to the tertiary center as direct admits from another inpatient setting.

Research assistants identified patients for the study who came to the tertiary center from another ED or inpatient setting via ambulance over a 14-month period (1/1/2007 to 3/31/2008). Since patients are never transferred to our tertiary center for elective reasons (physician preference, managed care or other insurance reasons, or for lateral levels of care), we are confident that all patients transferred were for HLOC. The time period examined was chosen such that all 570 patients' billing and reimbursement activities were complete, with accurate information regarding charges and reimbursement. Through these mechanisms, we are confident that we captured all HLOC transfer to the institution during this time period.

Each specialty department's centralized professional fee billing office used the list of patients, dates of birth, date of arrival and medical record numbers to provide admission service, length of stay, principle diagnosis, procedures performed, primary payer (insurance profile), charges, relative value unit (RVU) and reimbursement data. Data were entered and analyzed with purely descriptive statistics with Excel (version 12.3.0, Microsoft, Redmond, WA). We determined total patients, RVUs and charges and reimbursement by specialty. We calculated charges, reimbursement, and RVUs per patient. In order to compare to national benchmarks, we calculated reimbursement per RVU and average percent of Resource-Based Relative Value Scale (RBRVS) for all patients within each specialty.

National benchmarks for reimbursement per RVU were calculated from the 2006 Medical Group Management Association (MGMA) Compensation and Production Survey.[8] Since an RVU in 2007 was reimbursed according to RBRVS at $38.0870, if the account were paid this, we considered that reimbursement to be 100% of RBRVS. Therefore, we calculated percent of RBRVS by specialty by dividing the reimbursement per RVU by $38.0870.[9]

If reimbursement per RVU for HLOC transfers were found to be low compared to national benchmark, this could be explained by genuine poor reimbursement for HLOC transfers, or by global or specialty-specific low reimbursement specific to our institution alone. To determine which of these was the case, we compared each specialty's payer mix from this study site (reimbursement per RVU) with national benchmarks. The study was approved by the local Institutional Review Board.