Michigan has been unique in having a two-tiered Medicaid reimbursement system for emergency medicine since 2000. As in many states, Michigan’s emergency physicians found themselves facing the familiar challenge in the late ’90s of coding ED visits on the standard evaluation and management (E&M) levels 1–5, only to have to revisit the issue and fight for rightful payment when there was a disagreement with the state’s coders. The Michigan College of Emergency Physicians (MCEP) leadership at that time envisioned a way to save money for the state and benefit emergency physicians across the state.

Working from the premise that one of the most obvious outcomes that can be determined from a patient’s chart about their ED visit is whether they were discharged, admitted, observed, or transferred, the work group designed a system that offered a two-tiered reimbursement based upon the disposition of the patient. As patients requiring admission, observation, or transfer will generally require more complex decision making than those discharged, it was decided that such a system should reimburse at a higher level for those not discharged. This process was finally accepted in 2000 after years of effort by MCEP leaders and staff.

The new two-tiered reimbursement rates were set at levels that were a net gain for emergency physicians in Michigan versus the standard E&M codes. Charts are coded as per the usual E&M codes, but the modifier UA or UD—for admissions or discharges, respectively—is appended to the claim and determines the reimbursement. This saved both emergency physicians and the state money by avoiding the tedious process of appealing each chart when there was a disagreement in coding. It was truly a win-win and solidified MCEP’s position with state policymakers as an organization that truly values collaboration and creative problem-solving.

In the past 15 years, MCEP has built upon that foundation and maintained a good working relationship with the Michigan Department of Community Health, now the Department of Health and Human Services, and the Medicaid division in particular.

MCEP has continually lobbied for access to care for all patients and has fought hard to maintain and increase reimbursement to all Medicaid providers. MCEP stood with the patients it serves when it lobbied actively to expand Medicaid in Michigan. Michigan has had a tremendous surge in Medicaid patients since the Patient Protection and Affordable Care Act went into effect, hitting second-year enrollment targets before the end of the first year. When these patients seek care but the system is unable to handle the surge, emergency physicians step into the breach; policymakers in Michigan know that.