An effort to control costs could discourage patients from seeking emergency care.
OVER THE PAST YEAR OR so, a troubling trend has been reported in various media outlets: Some health insurers are denying claims from members who visited the emergency department for what they believed were actual emergencies. These policies involve the insurance company retroactively examining claims and approving or denying payment based on whether or not the incident was deemed a true emergency.
The problem is, most people aren't trained in medicine and don't know whether that pain in the belly is a burst appendix, which requires immediate medical intervention, or something harmless, such as gas pains that will pass on their own. Erring on the side of caution, many people go to the emergency room for an expert opinion. But even with health insurance, an increasing number of patients are finding out they're on the hook for a very large bill, but only after the insurance company has had an opportunity to review diagnostic tests that the patient didn't have prior to making the decision to visit the emergency department.
The American College of Emergency Physicians reports that certain insurers are keeping a list of "secret" diagnostic codes that, when tagged in a reimbursement submittal, will get the claim tossed out. The ACEP is raising the alarm that these sorts of policies may become standard across the industry if insurers who are enacting such policies aren't challenged, arguing that not using a measure called the "prudent layperson standard" violates federal law and discourages patients from seeking emergency care when they need it.
The "prudent layperson standard," is the measure by which most emergencies are determined to be emergencies, says Salvatore G. Rotella, Jr., partner at Buchanan Ingersoll & Rooney, PC, a full-service law firm based in Pittsburgh. Rotella is a health care attorney in the firm's Philadelphia office who represents health care providers in payment disputes with insurance companies. "The idea is, 'what would a normal person think?' If you or I woke up and had intense pain in the left side of the chest and couldn't breathe, we might reasonably think we're having a heart attack. And even if it turns out to be gas pains, you wouldn't get dinged for going to the emergency room to get it checked out" if your health insurance policy uses the prudent layperson standard as its benchmark for analyzing claims. "The visit would be paid for. Whereas if you woke up and your foot hurt, a prudent layperson wouldn't think, 'I'm going to the ER because I think I'm having a heart attack.' To a prudent layperson, a bit of pain in the bottom of your foot doesn't mean you're having a heart attack." And if you did go to the ER, it seems reasonable that you might be on the hook for paying the bill out of pocket.