Researchers from Santa Monica, California-based RAND Corporation and Boston’s Harvard School of Public Health reviewed 405 appeals of coverage denials for emergency services, lodged by privately insured enrollees at two of the nation’s largest managed care plans in California. The researchers found 90% of were won on appeal.
The study found disputes over payment for post service in emergency services was 52% for one plan and 34% in the second.
Researchers found a great inconsistency in how the prudent layperson standard was interpreted in initial coverage decisions over emergency services made by medical groups affiliated with the managed care plan and the coverage decisions made by the plan itself upon the patients’ appeals.
Although a federal law known as the Emergency Medical Treatment and Labor Act (EMTALA) requires hospital emergency departments to provide a medical screening exam and stabilize patients who visit emergency departments, insurance companies are not required to pay for these exams. 47 states have prudent layperson laws or a variation of the law, which require health plans to pay for emergency services a prudent layperson would think necessary to prevent serious injury. Those rules apply even if the emergency proves to be a false alarm.
Carolyn Roan Gresenz, PhD, from Rand Corporation, co-author of the study said, “The prevalence of emergency department cases among all appeals reflects a level of disagreement between lay and expert judgements about what constitutes emergency care under the prudent layperson standard. Furthermore, the high rate at which managed care enrollees win these appeals highlights significant disagreement in the interpretation of the prudent layperson standard among managed care providers.”