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

Prudent Layperson Standard Reinforced in Recent Medicaid Managed Care Rule


When the Centers for Medicare and Medicaid Services (CMS) released the Medicaid and CHIP Managed Care Final Rule back in late April, one provision will continue to protect payment for emergency physicians treating Medicaid managed care patients.

Prudent Layperson Standard

Specifically, the Prudent Layperson (PLP) standard for defining a medical emergency was upheld, which says that emergency physicians should receive reimbursement for evaluating and/or stabilizing managed care beneficiaries if the presenting condition is considered an emergency by a “prudent layperson.”

A prudent layperson is one “who possesses an average knowledge of health and medicine and could reasonably expect the absence of immediate medical attention to result in the following:

  • Placing the health of the individual or, with respect to a pregnant woman, the health of the woman or her unborn child in serious jeopardy
  • Serious impairment to bodily functions
  • Serious dysfunction of any bodily organ or part.”

When applying the PLP standard, CMS says the final determination should take into account the presenting symptoms rather than the final diagnosis. Also, CMS prohibits using lists of codes (either symptoms or final diagnosis) for denying claims “because we believe there is no way a list can capture every scenario that could indicate an emergency medical condition under the BBA (1997 Balanced Budget Act) provisions.”

CMS addressed the PLP standard in this recent final rule after several commenters, including the Emergency Department Practice Management Association, recommended reinforcement of the PLP along with a reiteration of the prohibition against limiting coverage and payment for emergency services based on approved lists of diagnosis codes.

PLP and Potentially Preventable Emergency Visits

Incidentally, the American College of Emergency Physicians (ACEP) used this same PLP standard to take issue with a recent Excellus BlueCross BlueShield report about “potentially preventable” emergency visits.

According to Fiercehealth, the Excellus report claimed that “millions of New Yorkers (as many as 9 out of 10) use the emergency room for conditions that could be treated in less expensive settings.” But ACEP says the report was flawed because it looked at patients’ final diagnoses, not their presenting symptoms.

“The data does not take into consideration the national ‘prudent layperson’ standard, which says emergency visits must be covered by insurance companies based on patients’ symptoms, not their final diagnoses,” ACEP said in a prepared statement. “It also directly contradicts data from the Centers for Disease Control and Prevention which says that the vast majority (96 percent) of emergency patients seek care appropriately.”

For more information, review the following resources:

— All rights reserved. For use or reprint in your blog, website, or publication, please contact us at cipromsmarketing@ciproms.com.


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.

© Copyright 2020