Experience. Integrity. Advocacy.
Experience. Integrity. Advocacy.

New Concerns Arise Over Application of Prudent Layperson Standard in the ED

Emergency physicians in Kansas and Missouri are raising new concerns about insurers refusing to pay or paying only a screening fee for patients being treated for conditions which they claim are non-urgent.

In a letter to Secretary Susan Mosier, MD, of the Kansas Department of Health and Environment’s Division of Public Health, the Emergency Department Practice Management Association (EDPMA) and the American College of Emergency Physicians (ACEP), along with their Kansas Chapter, claim that Kansas’ Medicaid managed care organizations (KanCare) are not reimbursing emergency physicians according to the federal prudent layperson standard, which “obligates Medicaid carriers and managed care organizations (MCOs) to reimburse emergency medical providers for the delivery of emergency medical services and care to Medicaid recipients.”

Specifically, these ED groups claim that KanCare MCOs have issued retrospective denials after emergency care has been rendered to the patient, claiming “the conditions by which the patient sought out emergency services did not constitute an emergency medical condition.” Since these cases were deemed ‘non-emergent,’ KanCare paid drastically reduced reimbursement at rates as low as $13.00. However, the conditions were ones that the emergency physicians felt were within the prudent layperson standard and should have been reimbursed.

In addition to not getting paid the full price for the emergency services they provided, physicians expressed concern over the lack of transparency and inclusion of ER physicians in defining “non-emergent” conditions as well as the cumbersome process currently in place for appealing such decisions.

In a separate press release, ACEP and members of its Missouri Chapter claim that Anthem Blue Cross Blue Shield (BCBS) has created a list of nearly 2,000 diagnoses which constitute “non-urgent” conditions and will not be covered if the patient goes to the emergency department. According to ACEP, however, some diagnoses on the list can be symptoms of actual medical emergencies and should be covered under the federal prudent layperson standard. They list the following examples:

  • “Chest pain on breathing” can be a life-threatening pulmonary embolism.
  • “Acute conjunctivitis,” if caused by gonorrhea, can cause blindness.
  • “Influenza,” which has killed hundreds of thousands of people over the past century, can be an emergency.  Thousands of people die from the flu each year.

According to ACEP, Anthem BCBS currently enforces this policy in Virginia and Kentucky, plans to roll it out in Missouri this summer, and is planning potential rollouts in Indiana and Ohio in the near future.

Meanwhile, in Indiana Anthem BCBS recently updated their ER Auto-Pay List for their Hoosier Healthwise, Healthy Indiana Plan, and Hoosier Care Connect plans effective April 1, 2017. According to the payer, that list reflects conditions any prudent layperson might consider an emergency. ED claims submitted with a diagnosis code from that list will be paid according to the level of service provided. Likewise, ED claims also will be paid if the service was authorized by Anthem, if the primary medical physician referred the member for treatment, or if the member was advised by the 24/7 NurseLine to go to the emergency room.

However, claims without any type of authorization from Anthem or a medical provider which do not have a diagnosis code from the Auto-Pay list are subject to Anthem’s “prudent layperson review of the medical record.” If upon review Anthem determines that the patient’s condition was not an emergency, then they will reimburse the physician for a screening fee, which is the equivalent of a level 99281 service.

While the prudent layperson standard is included in federal law, including the Affordable Care Act, and also is the law in more than 30 states, emergency physicians fear that attempts to replace the ACA may strip the prudent layperson standard protection for physicians and patients.

“If patients think they have the symptoms of a medical emergency, they should seek emergency care immediately and have confidence that the visit will be covered by their insurance,” said Rebecca Parker, MD, FACEP, president of ACEP.  “Patients cannot be expected to self-diagnose their medical conditions, which is why the ‘prudent layperson’ standard must also be included in any replacement legislation of the Affordable Care Act.”

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Charity Singleton Craig

Charity Singleton Craig is a freelance writer and editor who provides communications and marketing services for CIPROMS. She is responsible for creating, editing, and managing all content, design, and interaction on the company website and social media channels in order to promote CIPROMS as a thought leader in healthcare billing and management.


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