This applies 20/20 hindsight to possibly life-threatening conditions and it violates the national prudent layperson standard
designed to protect patients' health plan coverage of emergency care.
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).
Tavenner commitment to the prudent layperson standard
, which is part of the Affordable Care Act.
WA-ACEP had argued the state's plan violated the national prudent layperson standard
, which requires health insurance plans to base coverage of emergency care on a patient's symptoms and not their final diagnoses.
The nation's emergency physicians fully support the emergency care provisions in the law, such as inclusion of emergency services as an essential part of any health benefits package and the prudent layperson standard
, which guarantees that health plans base coverage on the patient's symptoms, not the final diagnosis.
The federal law that protects coverage of emergency care is the prudent layperson standard
, which requires health plans to cover visits to emergency departments based on an average person's belief that he or she may be suffering a medical emergency due to the person's symptoms, not the final diagnosis.
The nation's emergency physicians today applauded the leadership of the governor, saying her decision sends a clear message to all health plans to support the prudent layperson standard
, which requires coverage based on a patient's symptoms.
There are no alternative sources of medical care for these patients, according to the nation's emergency physicians, and it violates the federal prudent layperson standard
by basing coverage on the patient's final diagnosis, which a physician does not know at the time of triage.
The state is violating the federal Prudent Layperson standard
by applying it to managed care patients.
According to Prime Healthcare, Kaiser's tactics to avoid properly paying claims include making repeated and unnecessary demands for medical records, denying reimbursement for emergency medical services under the guise that the care was not medically necessary even though the Prudent Layperson Standard
is met on every occasion, retrospectively reviewing claims for emergency care, and demanding the transfer of Kaiser members to Kaiser's hospitals with no regard to the patients' medical condition and safety.