The Prudent Layperson Standard was specifically drafted to allow patients to get the services they need, when they need them.
McCaskills letter outlines Anthems potential violation of federal law by disapproving emergency room claims that may be required to be allowed under the Prudent Layperson Standard, a law that requires emergency room coverage where absence of immediate medical attention would place the health of the individual in serious jeopardy.
Emergency care is based on the average knowledge of health and medicine (prudent layperson standard
) that a delay in seeking immediate medical attention would have been hazardous to your health or life, and there was no Veterans Affairs Medical Center (VAMC) or other federal facility/provider readily available.
Reforms include: SB 50, that sets up a three-step process for denied care; HB 185, that sets up a prudent layperson standard
for judging emergency medical treatment; and HB 186, that requires companies to have a process for referral to specialized physicians.
* Prudent layperson standard
for emergencies: Thirty-one state laws specify automatic coverage for emergency medical conditions "of sufficient severity, including severe pain, that a prudent layperson, who possesses an average knowledge of health and medicine, could reasonably expect the absence of medical attention to result in placing the person's health in jeopardy."
The Act calls for a prudent layperson standard for defining medical emergencies, the prohibition of prior authorization requirements, a process to assure medically necessary care even after the patient has been stabilized, and methods for resolving disputes between EDs and health plans (American College of Emergency Physicians, "Questions and Answers: Access to Emergency Medical Services Act" undated).
Third, while the prudent layperson standard is gaining in popularity, we do not know whether it might discriminate against immigrants or persons with low educational achievement, who perhaps have different ideas of emergency situations than those belonging to the average American.
An often cited definition of quality hails from the Institute of Medicine (1990): "the degree to which health services for individuals and populations increase the likelihood of desired health outcomes and are consistent with current professional knowledge." Absent a precise definition, quality may include issues ranging from the amount of time spent in a health care practitioner's waiting room to the application of a "prudent layperson standard
" in determining payment for emergency room care.
To be called an emergency, it has to be decided "if in the mind of an average person, it was a life-threatening situation or that if a delay hi care would be life threatening." This is often referred to as the prudent layperson standard