What Is an FSED?

The concept of the free-standing emergency department, or FSED, is not new. As long ago as the 1970s, FSEDs were regarded as an option for providing services to rural communities, and they’re getting another look in recent years.

An FSED is exactly what it sounds like. David Ernst, MD, a fellow with the American College of Emergency Physicians describes the FSED as “cutting the emergency department out of the hospital and moving it.” FSEDs don’t have operating or inpatient rooms, and patients requiring inpatient care must be transported to a hospital.

There are two types of FSEDs: off-campus emergency departments and the independent free-standing emergency centers. A hospital-based OCED is more common and is run by a hospital similarly to an outpatient department. These facilities are state-licensed and financially integrated with the governing hospital. They must comply with the same requirements as the parent hospital emergency department.

IFECs are owned and run by for-profit, non-hospital entities. They offer similar services comparable to OCEDs but are not bound by federal ED regulations.

How Do FSEDs Work?

FSEDs offer emergency care, plus services like medical imaging, lab services and physician visits. Most patients are walk-ins, rather than arriving by ambulance. OCEDs bill for services under the Medicare Part B Fee Schedule just as non-free-standing emergency departments do. Private insurers typically treat them as in-network providers along with their associated hospitals.

Because IFECs aren’t affiliated with hospitals, they are not recognized as provider-based facilities by the Centers for Medicare and Medicaid Studies. In other words, they cannot bill Medicare or Medicaid. Moreover, private insurers often consider IFECs to be out-of-network providers. State and municipal laws may impose additional requirements. IFECs are harder to sustain financially in areas with large Medicare and Medicaid populations (like rural areas).

Although Medicare reimbursements are federally regulated, FSED licensure is regulated at the state level. Currently, only a few states have passed specific legislation allowing construction and licensing of IFECs. Some states only allow OCEDs, while the rest do not have any legislation concerning FSEDs.

Factors to Consider with FSED Employment

Factors you should consider when evaluating physician jobs in FSEDs are mostly the same as you would evaluate with other physician jobs, including salary, benefits, on-call rules, scheduling and financial coverage for continuing education. In addition, however, you should be more vigilant when considering physician jobs in IFECs. That’s because IFECs don’t bill Medicare and Medicaid, and private insurers may not consider them to be “in-network,” so revenue cycles may be longer. Moreover, IFECs located in rural areas where a larger proportion of the population is on Medicare or Medicaid may make this care delivery model unsustainable financially. So, you could be looking for a new job sooner than you had expected.

Advantages of Working in an FSED

The overwhelming majority of FSED patients are walk-ins, and fewer than 5 percent of FSED patients have to be admitted for inpatient care. While some FSEDs can observe patients overnight, most transfer these patients to hospitals for subspecialty needs. Patient satisfaction with FSEDs is high, due to much shorter wait times than traditional emergency departments and due to more convenient locations.

Studies that have been done on FSEDs find that the quality of care is equal to that provided by hospitals, even for serious and time-critical needs. Because FSEDs have lower overhead than hospital emergency departments, there is a significant opportunity for profit. Some FSEDs even partner with local specialists and offer services like IV medical infusions that might otherwise have to be delivered in a hospital infusion center, allowing patients to receive care without being admitted to a hospital.

Disadvantages of Working in an FSED

The main disadvantage of working in an IFEC FSED is that there is no Medicare or Medicaid billing. Additionally, some believe that the very convenience of FSEDs can steer patients away from lower cost primary care or urgent care, further fragmenting medical care and escalating costs. Though the concept has been around for decades, the financial viability of FSEDs is something that is continually evolving depending on things like insurer regulations, federal and state laws and the general condition of the economy.

As of the end of 2015, there were around 400 FSEDs in 32 states, and numbers are expected to grow as demand for medical care grows.

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