The clash of clinical vs. coverage/payment concerns

by Trey La Charité, MD

An emergency department (ED) physician diagnosed a patient with pneumonia. He was concerned about a possible nosocomial etiology given the patient’s recent hospital discharge for problems related to atrial fibrillation. Because the patient’s Pneumonia Severity Index score was 4 and his CURB-65 score was 2, the ED physician wanted to admit the patient to the hospital for treatment with broad-spectrum intravenous antibiotics. However, after discussion with the ED physician, the admitting hospitalist denied the admission on the grounds that the patient did not meet either InterQual or Milliman criteria for inpatient admission.