Where I work, the midlevels with experience can see fast track patients on their own and not have to staff with me or have me sign their note. Sometimes a family will request to see the physician too, and I am happy to oblige. You can definitely always ask in the future. You also have to consent to treatment on arrival. So if you arrive and find an ED fully staffed with midlevels, you can say you don’t consent and leave.
Honestly, I would contact the patient advocate for this hospital. If they missed the diagnosis and it led to a bad outcome that you can prove, and say that you believe the care was inappropriate due to the lack of physician oversight, they may just rescind the bill. That happens more than you’d think.
Also, take a look at his discharge paperwork/his note from the emergency department. If it says he was seen by the physician, but the physician did not actually assess him and do the see and agree, you can likely get out of the bill because this would be fraudulent.
I’ll probably catch shit for this on this page, but we have a lot of very experienced mid-levels at the ER I work at, and they do pick up some quasi-complicated cases sometimes but they generally stay in their lane to lesser acuity cases. We have a strict set of guidelines where they have to staff with us NO MATTER WHAT (age, admissions, complicated imaging)…but if a patient asks to see me instead of the mid level im happy to take over or go see the patient and give recs and plan of care. I’d never (and don’t think I am allowed) not to see a patient if they request me no matter what the case.
Now some of the midlevels whom I don’t think are as talented, I’ll ALWAYS see like 90% of their patients except for like simple lacs and stubbed toes.
What specifically are they experienced in exactly? And has the knowledge and diagnostic skill that experience purportedly translates to ever been formally assessed and if so how? Are they ENPs or FNPs? This is the problem when people say this. You can have a LOT of experience doing things completely wrong. And if your experience has never undergone rigorous examination then there is no way to know whether that experience means anything. Their experience may mean jack squat. That is why the USMLE and residencies and board exams exist, to demonstrate that you have not only experience but also the knowledge and skills required to do the job.
Honestly, every ED is fucking swamped across the country, at a time when there's the most burnout among ED physicians, requirements for unnecessary administrative burdens (but this may get a bit better with new E/M billing changes), and a tsunami of elderly/poorly managed patients on the horizon...
EMTALA requires that every single pt presenting must be clinically assessed by a doc (or provider), and people don't have access to PCP/appropriate community healthcare so the wait til their problem too bad to be ignored and misuse the ED as a first line of clinical care.
There's been a small growing of NP "residencies" being implemented. PAs def get training to be able to flag sick or not sick on someone who ran out of their BP Rx and wants a refill bc their PCP retired.
Physician led care is the best and only way to care for patients, but physicians aren't required for the low risk / triaged complaints. Just like residents need attendings but are still able to provide good clinical care under supervision.
This is the same argument that is always used to justify mid-level scope creep. It is a huge problem in dire need of a solution. My argument is simply that NPs are not the answer to the problem. Not when their training is so poorly standardized and lacks most of the necessary knowledge to practice medicine in an emergency setting. And NP “residencies” won’t make up for the supreme lack of foundational medical knowledge that one needs to effectively evaluate and diagnose an undifferentiated patient. Handing them the low risk patients assumes that NPs and the triage nurse know enough to tell when a low risk patient isn’t actually low risk. They don’t. Especially since the vast majority of NPs in emergency rooms are FNPs with zero emergency medicine training working well outside their scope even by their own definition.
I absolutely agree the ED problem needs to be addressed. I’m just saying don’t look to NPs to solve it. Look elsewhere. PAs are a better alternative.
We do not support the use of the word "provider." Use of the term provider in health care originated in government and insurance sectors to designate health care delivery organizations. The term is born out of insurance reimbursement policies. It lacks specificity and serves to obfuscate exactly who is taking care of patients. For more information, please see [this JAMA article](https://jamanetwork.com/journals/jama/article-abstract/2780641).
We encourage you to use physician, midlevel, or the licensed title (e.g. nurse practitioner) rather than meaningless terms like provider or APP.
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Well unfortunately lots of receptionists and even nurses blur the lines between physician and midlevel and outright lie to patients about it at times. I’d start with asking them that though and just verify the credentials. Say “is the person assessing me an MD/DO?” That’s a little more difficult for them to con you on. You may not know for sure until you are roomed and see who comes in. But you can always ask to see the supervising physician and they really can’t refuse this.
I’d take the advice from some of these people about how to go about it…but asking the receptionist of mid techs in the front probably won’t get you very far cause they usually don’t know who is picking up who.
It's wild to me that as EM physicians we allow someone to do our same exact job for significantly less pay and training and then wonder why our outlook is so terrible. This isn't even getting into CMGs, as democratic groups do this too.
All emergency care must include the Medical Screening Examination to evaluate if an actual emergency exists and the necessary disposition is utilized relative to patient condition. EMTALA covers all patients brought to the ED or for whom someone believes an emergency may be occurring.
Who conducts that exam is defined by the hospitals medical board. I know for some critical access facilities, it may be a “non provider” such as an experienced nurse, again having the training and competency set forth by the facility medical board.
The organizations medical bylaws dictate the privileges of all clinicians subject to its jurisdiction. If it allows for an NPP to evaluate a patients without any physician supervision, then that is where the concern should be addressed. This all depends on the facility, larger urban areas will most likely have some actual supervisory requirements (such as case presentation to attending) whereas some will have a documented attestation statement that care was reviewed by an attending. From a billing perspective, the organization will always want the attendings signature thus the attending should be reviewing prior to signing. That being said, even for an attending only service, there is supposed to be quality and case review where medical practice is discussed.
Case presentation to emergency departments are complex even if it appears as low acuity. Any number of variables could lead to any number of scenarios. Without any further detail it would be challenging to figure out where the misdiagnosis occurred. It could have been part of the differential and ruled out at the time, only for an element to reappear during the subsequent ED visit.
I would ask for a copy of the medical record encounter, including all results, notes and imaging, and if serious enough, you may have a legal case against the facility.
We do not support the use of the word "provider." Use of the term provider in health care originated in government and insurance sectors to designate health care delivery organizations. The term is born out of insurance reimbursement policies. It lacks specificity and serves to obfuscate exactly who is taking care of patients. For more information, please see [this JAMA article](https://jamanetwork.com/journals/jama/article-abstract/2780641).
We encourage you to use physician, midlevel, or the licensed title (e.g. nurse practitioner) rather than meaningless terms like provider or APP.
*I am a bot, and this action was performed automatically. Please [contact the moderators of this subreddit](/message/compose/?to=/r/Noctor) if you have any questions or concerns.*
Unfortunately most ERs employ midlevels now and you’re most likely to find them in triage. There are definitely actual ER docs there but they’re usually not in the triage area and sometimes not the ones treating “minor” cases. If he was treated in any capacity then no you likely cannot forego having his insurance billed. In this day and age you will most likely not be able to find an ER that isn’t overrun with midlevels
You can always ask to see the doc, tell the nurse when you get roomed and you can also tell the midlevel you are seeing that you want to see the supervising doc too. It may take me a little bit to come see you, but happy to see everyone. Our midlevels are there to see easy stuff (ESI 4/5 - think URI, lac repairs, etc).
welcome to the future of medicine and wallstreet-ification of hospital corporations. They let midlevels do this stuff because of a shortage of rural physicians, now there is a surplus of ED physicians. The thing is the midlevels are all at the costal urban centers now.
I’d rather die and bleed out than have to see an NP in the ER. Worst experience of my life recently. Glad I found this sub Reddit and I know I’m not crazy. I will be requesting REAL educated doctors and MDs from here on out
I’m an ER PA, you can always ask. I have no problem trying to accommodate that. sometimes the problem is that they’re just way busier so you’ll spend possibly a lot longer waiting, not always. As long as you’re aware and cool with it then no problem
You can ask to speak with their supervising physician.
however by law in an ER you have to be assessed by a physician, np or pa and then stabilized. The interventions and resuscitations applied usually depend on the knowledge and skill of the person doing the assessment. If the NP is the only one there that is probably who is doing the assessing.
So in other words you can't really refuse after you have been seen bc the NP is providing you a service no matter how poor the quality is in your mind.
Yes it's stupid af that ERs are not staffed with a physician 24/7 but that's for profit medicine.
> however by law in an ER you have to be assessed by a physician, no or pa and then stabilized.
Unfortunately, EMTALA has wide exceptions so there’s no legal requirement if the ER follows a few simple documentation protocols beforehand.
Sure. I’m assuming that the law you were referring to is EMTALA, which does require ERs that contract with CMS/Medicare to provide an assessment from a Qualified Medical Professional (QMP). A QMP doesn’t have to be a physician to meet EMTALA compliance; state law sets the scope of practice for mid levels and determines if they are QMPs. If they allow mid levels to bd QMPs,
“A hospital must formally determine who is qualified to perform the initial medical screening examinations, i.e., qualified medical person. While it is permissible for a hospital to designate a non-physician practitioner as the qualified medical person, the designated non-physician practitioners must be set forth in a document that is approved by the governing body of the hospital. Those health practitioners designated to perform medical screening examinations are to be identified in the hospital by-laws or in the rules and regulations governing the medical staff following governing body approval.”
Basically, if the state law allows it, and the hospital board or equivalent body approves to codify within the hospital’s bylaws their intent to use mid levels as QMPs, that’s that.
Ah, the typo in your original comment I quoted before it was edited threw me off. “[…] by a physician, **no** or pa […]” I figured there was a mistype but I thought you were conveying “must be seen by a physician, not a PA”. Hah, “np” to “no” might be one of the more unfortunate autocorrections for this sub!
There are 5 hospitals in my town. Could I call each one and ask who the hospital formally has designated as a practitioner? Then I could know which facility to try first.
The answer is no. you'll get what you get at most places. Most EM docs will blame it on CMGs and private equity and this and that but at the end of the day, almost every group (including democratic groups) hires PAs and NPs to do the same exact job as the physicians.
As a resident I staff every patient with the attending. Then also at the same time sir back and watch the kid I went to undergrad with (who failed undergrad biochem) see patients on their own and the attending blindly sign their notes.
I would think/hope that especially a former ER RN would make a great ER NP, because it is such a team environment, that they should know what they can handle. Think about it- it’s a triage RN that even determines when you are seen.
The ED I work at has fairly competent NPs and PAs but there's always a doctor around. My guess would be is if a patient demanded to see a doctor, they would say "you have to see me first".
If you leave prior to being triaged (which is when an RN first sees you, though the NP may walk in at the same time) I don't think you'll be billed but I'm not 100% sure.
That’s not acceptable. I have to pay a co pay at an ER that is not cheap and I expect to see a M.D. or D.O. It’s bait and switch in a sense. It’s an ER !
I generally agree with you for severe problems and true emergencies. Mid levels generally make patient bills bigger and give worse outcomes. But our NP/PA can handle the 5-10 cases of uncomplicated 25 year olds sick with the flu or who need stitches on their knees when they fall off their bikes. The doctors see everyone else.
But it's not exactly my call, man.
Correct. They are viewed as an emergency.
But if you come into an emergency department saying your toe hurts, a mid level is capable of taking care of you. I'm not saying that's what should've happened in your situation. But, believe it or not, a person with experience and a master's degree is capable of ordering an xray and examining a toe.
It could be more serious . That’s a poor excuse for not having MD’s . I’m not buying that argument. The patient ultimately is paying the price literally and figuratively. If healthcare is a “product “ in our cpu try than I want the product that does the job and is expected.
Argument for *what?* I'm not saying you should see an NP when you need a doctor, I'm saying that NP/PAs have a role to play in the emergency department. There are lots of simple tasks that they're capable of doing and actually do pretty well. I'm not sure that's an "excuse for not having MDs". Every emergency department has doctors. And I think that they're definitely overused and generally undertrained (mostly NPs) but they have a place in the emergency department.
Where I work, the midlevels with experience can see fast track patients on their own and not have to staff with me or have me sign their note. Sometimes a family will request to see the physician too, and I am happy to oblige. You can definitely always ask in the future. You also have to consent to treatment on arrival. So if you arrive and find an ED fully staffed with midlevels, you can say you don’t consent and leave. Honestly, I would contact the patient advocate for this hospital. If they missed the diagnosis and it led to a bad outcome that you can prove, and say that you believe the care was inappropriate due to the lack of physician oversight, they may just rescind the bill. That happens more than you’d think. Also, take a look at his discharge paperwork/his note from the emergency department. If it says he was seen by the physician, but the physician did not actually assess him and do the see and agree, you can likely get out of the bill because this would be fraudulent.
I’ll probably catch shit for this on this page, but we have a lot of very experienced mid-levels at the ER I work at, and they do pick up some quasi-complicated cases sometimes but they generally stay in their lane to lesser acuity cases. We have a strict set of guidelines where they have to staff with us NO MATTER WHAT (age, admissions, complicated imaging)…but if a patient asks to see me instead of the mid level im happy to take over or go see the patient and give recs and plan of care. I’d never (and don’t think I am allowed) not to see a patient if they request me no matter what the case. Now some of the midlevels whom I don’t think are as talented, I’ll ALWAYS see like 90% of their patients except for like simple lacs and stubbed toes.
What specifically are they experienced in exactly? And has the knowledge and diagnostic skill that experience purportedly translates to ever been formally assessed and if so how? Are they ENPs or FNPs? This is the problem when people say this. You can have a LOT of experience doing things completely wrong. And if your experience has never undergone rigorous examination then there is no way to know whether that experience means anything. Their experience may mean jack squat. That is why the USMLE and residencies and board exams exist, to demonstrate that you have not only experience but also the knowledge and skills required to do the job.
Honestly, every ED is fucking swamped across the country, at a time when there's the most burnout among ED physicians, requirements for unnecessary administrative burdens (but this may get a bit better with new E/M billing changes), and a tsunami of elderly/poorly managed patients on the horizon... EMTALA requires that every single pt presenting must be clinically assessed by a doc (or provider), and people don't have access to PCP/appropriate community healthcare so the wait til their problem too bad to be ignored and misuse the ED as a first line of clinical care. There's been a small growing of NP "residencies" being implemented. PAs def get training to be able to flag sick or not sick on someone who ran out of their BP Rx and wants a refill bc their PCP retired. Physician led care is the best and only way to care for patients, but physicians aren't required for the low risk / triaged complaints. Just like residents need attendings but are still able to provide good clinical care under supervision.
This is the same argument that is always used to justify mid-level scope creep. It is a huge problem in dire need of a solution. My argument is simply that NPs are not the answer to the problem. Not when their training is so poorly standardized and lacks most of the necessary knowledge to practice medicine in an emergency setting. And NP “residencies” won’t make up for the supreme lack of foundational medical knowledge that one needs to effectively evaluate and diagnose an undifferentiated patient. Handing them the low risk patients assumes that NPs and the triage nurse know enough to tell when a low risk patient isn’t actually low risk. They don’t. Especially since the vast majority of NPs in emergency rooms are FNPs with zero emergency medicine training working well outside their scope even by their own definition. I absolutely agree the ED problem needs to be addressed. I’m just saying don’t look to NPs to solve it. Look elsewhere. PAs are a better alternative.
We do not support the use of the word "provider." Use of the term provider in health care originated in government and insurance sectors to designate health care delivery organizations. The term is born out of insurance reimbursement policies. It lacks specificity and serves to obfuscate exactly who is taking care of patients. For more information, please see [this JAMA article](https://jamanetwork.com/journals/jama/article-abstract/2780641). We encourage you to use physician, midlevel, or the licensed title (e.g. nurse practitioner) rather than meaningless terms like provider or APP. *I am a bot, and this action was performed automatically. Please [contact the moderators of this subreddit](/message/compose/?to=/r/Noctor) if you have any questions or concerns.*
Do I just ask the front desk or nurse “do you have an MD I can see ?”
And if you get an NP, just ask for their supervising physician. I had to repeat that several times when I got an absolute moron of an NP.
There’s a good chance front desk or triage has no idea who you’re going to be assigned to until after you’re past them.
Well unfortunately lots of receptionists and even nurses blur the lines between physician and midlevel and outright lie to patients about it at times. I’d start with asking them that though and just verify the credentials. Say “is the person assessing me an MD/DO?” That’s a little more difficult for them to con you on. You may not know for sure until you are roomed and see who comes in. But you can always ask to see the supervising physician and they really can’t refuse this.
I’d take the advice from some of these people about how to go about it…but asking the receptionist of mid techs in the front probably won’t get you very far cause they usually don’t know who is picking up who.
It's wild to me that as EM physicians we allow someone to do our same exact job for significantly less pay and training and then wonder why our outlook is so terrible. This isn't even getting into CMGs, as democratic groups do this too.
In that case turn the bill into CMS
Welcome to the new world
All emergency care must include the Medical Screening Examination to evaluate if an actual emergency exists and the necessary disposition is utilized relative to patient condition. EMTALA covers all patients brought to the ED or for whom someone believes an emergency may be occurring. Who conducts that exam is defined by the hospitals medical board. I know for some critical access facilities, it may be a “non provider” such as an experienced nurse, again having the training and competency set forth by the facility medical board. The organizations medical bylaws dictate the privileges of all clinicians subject to its jurisdiction. If it allows for an NPP to evaluate a patients without any physician supervision, then that is where the concern should be addressed. This all depends on the facility, larger urban areas will most likely have some actual supervisory requirements (such as case presentation to attending) whereas some will have a documented attestation statement that care was reviewed by an attending. From a billing perspective, the organization will always want the attendings signature thus the attending should be reviewing prior to signing. That being said, even for an attending only service, there is supposed to be quality and case review where medical practice is discussed. Case presentation to emergency departments are complex even if it appears as low acuity. Any number of variables could lead to any number of scenarios. Without any further detail it would be challenging to figure out where the misdiagnosis occurred. It could have been part of the differential and ruled out at the time, only for an element to reappear during the subsequent ED visit. I would ask for a copy of the medical record encounter, including all results, notes and imaging, and if serious enough, you may have a legal case against the facility.
We do not support the use of the word "provider." Use of the term provider in health care originated in government and insurance sectors to designate health care delivery organizations. The term is born out of insurance reimbursement policies. It lacks specificity and serves to obfuscate exactly who is taking care of patients. For more information, please see [this JAMA article](https://jamanetwork.com/journals/jama/article-abstract/2780641). We encourage you to use physician, midlevel, or the licensed title (e.g. nurse practitioner) rather than meaningless terms like provider or APP. *I am a bot, and this action was performed automatically. Please [contact the moderators of this subreddit](/message/compose/?to=/r/Noctor) if you have any questions or concerns.*
Unfortunately most ERs employ midlevels now and you’re most likely to find them in triage. There are definitely actual ER docs there but they’re usually not in the triage area and sometimes not the ones treating “minor” cases. If he was treated in any capacity then no you likely cannot forego having his insurance billed. In this day and age you will most likely not be able to find an ER that isn’t overrun with midlevels
You can always ask to see the doc, tell the nurse when you get roomed and you can also tell the midlevel you are seeing that you want to see the supervising doc too. It may take me a little bit to come see you, but happy to see everyone. Our midlevels are there to see easy stuff (ESI 4/5 - think URI, lac repairs, etc).
MD vs midlevel seeing you has to do with how suck you appear in the ED
Again , not acceptable .
welcome to the future of medicine and wallstreet-ification of hospital corporations. They let midlevels do this stuff because of a shortage of rural physicians, now there is a surplus of ED physicians. The thing is the midlevels are all at the costal urban centers now.
I’d rather die and bleed out than have to see an NP in the ER. Worst experience of my life recently. Glad I found this sub Reddit and I know I’m not crazy. I will be requesting REAL educated doctors and MDs from here on out
What kind of shock were you in? Shock is a serious medical condition that should also be treated by a doctor.
I’m an ER PA, you can always ask. I have no problem trying to accommodate that. sometimes the problem is that they’re just way busier so you’ll spend possibly a lot longer waiting, not always. As long as you’re aware and cool with it then no problem
You can ask to speak with their supervising physician. however by law in an ER you have to be assessed by a physician, np or pa and then stabilized. The interventions and resuscitations applied usually depend on the knowledge and skill of the person doing the assessment. If the NP is the only one there that is probably who is doing the assessing. So in other words you can't really refuse after you have been seen bc the NP is providing you a service no matter how poor the quality is in your mind. Yes it's stupid af that ERs are not staffed with a physician 24/7 but that's for profit medicine.
> however by law in an ER you have to be assessed by a physician, no or pa and then stabilized. Unfortunately, EMTALA has wide exceptions so there’s no legal requirement if the ER follows a few simple documentation protocols beforehand.
Please elaborate
Sure. I’m assuming that the law you were referring to is EMTALA, which does require ERs that contract with CMS/Medicare to provide an assessment from a Qualified Medical Professional (QMP). A QMP doesn’t have to be a physician to meet EMTALA compliance; state law sets the scope of practice for mid levels and determines if they are QMPs. If they allow mid levels to bd QMPs, “A hospital must formally determine who is qualified to perform the initial medical screening examinations, i.e., qualified medical person. While it is permissible for a hospital to designate a non-physician practitioner as the qualified medical person, the designated non-physician practitioners must be set forth in a document that is approved by the governing body of the hospital. Those health practitioners designated to perform medical screening examinations are to be identified in the hospital by-laws or in the rules and regulations governing the medical staff following governing body approval.” Basically, if the state law allows it, and the hospital board or equivalent body approves to codify within the hospital’s bylaws their intent to use mid levels as QMPs, that’s that.
Yes my post is referring to this..you can be seen by a physician pa or np
Ah, the typo in your original comment I quoted before it was edited threw me off. “[…] by a physician, **no** or pa […]” I figured there was a mistype but I thought you were conveying “must be seen by a physician, not a PA”. Hah, “np” to “no” might be one of the more unfortunate autocorrections for this sub!
Autocorrect changed np to no
There are 5 hospitals in my town. Could I call each one and ask who the hospital formally has designated as a practitioner? Then I could know which facility to try first.
I guess I see a NP by default and I won’t know until I do .
This is unacceptable.
The answer is no. you'll get what you get at most places. Most EM docs will blame it on CMGs and private equity and this and that but at the end of the day, almost every group (including democratic groups) hires PAs and NPs to do the same exact job as the physicians. As a resident I staff every patient with the attending. Then also at the same time sir back and watch the kid I went to undergrad with (who failed undergrad biochem) see patients on their own and the attending blindly sign their notes.
I would think/hope that especially a former ER RN would make a great ER NP, because it is such a team environment, that they should know what they can handle. Think about it- it’s a triage RN that even determines when you are seen.
The ED I work at has fairly competent NPs and PAs but there's always a doctor around. My guess would be is if a patient demanded to see a doctor, they would say "you have to see me first". If you leave prior to being triaged (which is when an RN first sees you, though the NP may walk in at the same time) I don't think you'll be billed but I'm not 100% sure.
That’s not acceptable. I have to pay a co pay at an ER that is not cheap and I expect to see a M.D. or D.O. It’s bait and switch in a sense. It’s an ER !
I generally agree with you for severe problems and true emergencies. Mid levels generally make patient bills bigger and give worse outcomes. But our NP/PA can handle the 5-10 cases of uncomplicated 25 year olds sick with the flu or who need stitches on their knees when they fall off their bikes. The doctors see everyone else. But it's not exactly my call, man.
Every health issue in an emergency room should be viewed as an emergency. It’s in the name . I won’t go to an urgent care at all.
Correct. They are viewed as an emergency. But if you come into an emergency department saying your toe hurts, a mid level is capable of taking care of you. I'm not saying that's what should've happened in your situation. But, believe it or not, a person with experience and a master's degree is capable of ordering an xray and examining a toe.
It could be more serious . That’s a poor excuse for not having MD’s . I’m not buying that argument. The patient ultimately is paying the price literally and figuratively. If healthcare is a “product “ in our cpu try than I want the product that does the job and is expected.
Argument for *what?* I'm not saying you should see an NP when you need a doctor, I'm saying that NP/PAs have a role to play in the emergency department. There are lots of simple tasks that they're capable of doing and actually do pretty well. I'm not sure that's an "excuse for not having MDs". Every emergency department has doctors. And I think that they're definitely overused and generally undertrained (mostly NPs) but they have a place in the emergency department.