Skip to content
  • About
  • Contact
  • Contribute
  • Book
  • Careers
  • Podcast
  • Recommended
  • Speaking
  • All
  • Physician
  • Practice
  • Policy
  • Finance
  • Conditions
  • .edu
  • Patient
  • Meds
  • Tech
  • Social
  • Video
    • All
    • Physician
    • Practice
    • Policy
    • Finance
    • Conditions
    • .edu
    • Patient
    • Meds
    • Tech
    • Social
    • Video
    • About
    • Contact
    • Contribute
    • Book
    • Careers
    • Podcast
    • Recommended
    • Speaking

Retrospective refusal of payment based upon final diagnosis compromises patients’ welfare

David Hoke, MD, MBE, Kenneth V. Iserson, MD, MBA, and Jesse Basford, MD
Policy
March 29, 2021
Share
Tweet
Share

My patient was very upset. The 34-year-old mother of two young children had come to the emergency department (ED) with abdominal pain despite her COVID-19 concerns. I had just told her that she had a benign ovarian cyst rather than the life-threatening condition that she had imagined. She was happy with the diagnosis, but she feared that her employer-supplied health insurance would not cover this “non-emergent” diagnosis. How could it be, I thought, that this intelligent woman should be penalized by her insurance company for not diagnosing her own painful condition—a task that I could not accomplish without diagnostic tests?

In 1997, Congress first defined the Prudent Layperson Standard (PLS), requiring health maintenance organizations (HMOs) to cover emergency services for enrolled Medicare and Medicaid patients. They specified that covered services would include evaluation and/or treatment of any medical condition that a prudent layperson, possessing an average knowledge of medicine and health, believes would result in significant harm if he or she failed to seek care. Such conditions include serious pain, conditions that might place the health of the individual (or, concerning a pregnant woman, the health of the woman or her unborn child) in serious jeopardy, or cause serious impairment to bodily functions or serious dysfunction of any bodily organ or part. This legal standard was reaffirmed in the 2010 Patient Protection and Affordable Care Act.

Who is the “prudent layperson” that this law was designed to protect? It is generally recognized as a sensible and careful person without professional or specialized medical knowledge who acts wisely and judiciously when seeking care. Congress subsequently expanded the protections afforded by the PLS to patients covered by commercial insurance. In doing so, they meant to shield people from profit-oriented insurance companies, ensuring their coverage for emergency medical conditions.

Recently, some insurers, including Anthem Insurance in several states and Blue Cross and Blue Shield of Mississippi, have challenged these protections. With counterintuitive logic seemingly designed to increase profits at their clients’ expense, they agreed to pay only for ED visits when patients’ final diagnosis—not their presenting complaints—met the law’s criteria. This premise is counter to the practice of medicine – in which a history and physical examination suggest a differential diagnosis, and diagnostic tests rule in or out specific conditions. Not only does this harm patients whose bills are retrospectively denied, but also—and perhaps more tragically—may dissuade those with symptoms of severe illness or injury from accessing emergency care in a timely manner.

Laypersons and physicians identify medical emergencies differently. Even health care professionals may be challenged to determine whether an emergent medical condition exists, and the definition of an emergency varies among specialties. The prudent layperson standard is designed to protect patients in this realm of uncertainty.

To be clear, the American College of Emergency Physicians asserts that refusing to honor commitments to provide health care coverage under the prudent layperson standard is not only bad policy and illegal, but it is clearly unethical. Besides being potentially harmful, it penalizes patients who, in good faith, go to EDs expecting to use their health insurance for what they believe is a threat to their health and well-being. While some may counter that using the discharge diagnosis rather than the presenting complaint does not explicitly limit care, stop patients from going to the ED, or tell doctors what tests or treatments they can order, it implicitly does all these things. Allowing patients to believe that their insurance will not cover some or all necessary interventions undermines respect for patient judgment to achieve a corporate benefit. This is nothing short of fear-mongering; using such an arbitrary post-hoc analysis disrespects patients’ autonomy and deviates wildly from established professional, ethical, and societal values.

ACEP is working to protect patients and uphold the prudent layperson standard. And there is some good news. Along with the Medical Association of Georgia, ACEP filed suit in federal court in 2018 to halt Anthem’s new policy in Georgia. The District Court initially dismissed it for the Northern District of Georgia. However, recently, the U.S. Appeals Court for the 11th Circuit overturned the lower court’s dismissal, allowing the suit to proceed. They specifically note that using a trained physician’s assessment to retrospectively determine if a visit is an emergency is irrelevant. “The prudent layperson standards ask what someone with ‘average knowledge of health and medicine’ would think is an emergency based on the severity of ‘acute symptoms.’”

The practice of retrospective refusal of payment based upon final diagnosis compromises patients’ welfare and their fair access to care and denies emergency physicians the opportunity to provide professionally to their patients. It behooves patient-care advocates, clinicians, health care and insurance oversight bodies, and the political system to eliminate this tragic and unnecessary roadblock to seeking health care in an already complicated, expensive, and stressful medical system that is now in a pandemic crisis.

David Hoke, Kenneth V. Iserson, and Jesse Basford are emergency physicians.

Image credit: Shutterstock.com 

Prev

No mass shooting is "worse" than another mass shooting

March 29, 2021 Kevin 3
…
Next

How to stay relevant post-retirement

March 29, 2021 Kevin 2
…

Tagged as: Public Health & Policy

Post navigation

< Previous Post
No mass shooting is "worse" than another mass shooting
Next Post >
How to stay relevant post-retirement

ADVERTISEMENT

Related Posts

  • Are patients using social media to attack physicians?

    David R. Stukus, MD
  • The president’s plan for payment parity goes against what patients want

    Lawrence John, MD
  • You are abandoning your patients if you are not active on social media

    Pat Rich
  • Are pediatric hospitals ready to embrace value-based payment models?

    Johanna Vidal Phelan, MD, MBA
  • A love letter to patients

    Marcie Costello
  • Patients are not passengers

    Christopher Noll, RN, MSN

More in Policy

  • Why nearly 800 U.S. hospitals are at risk of shutting down

    Harry Severance, MD
  • Innovation is moving too fast for health care workers to catch up

    Tiffiny Black, DM, MPA, MBA
  • How pediatricians can address the health problems raised in the MAHA child health report

    Joseph Barrocas, MD
  • How reforming insurance, drug prices, and prevention can cut health care costs

    Patrick M. O'Shaughnessy, DO, MBA
  • Bundled payments in Medicare: Will fixed pricing reshape surgery costs?

    AMA Committee on Economics and Quality in Medicine, Medical Student Section
  • Who gets to be well in America: Immigrant health is on the line

    Joshua Vasquez, MD
  • Most Popular

  • Past Week

    • Why primary care doctors are drowning in debt despite saving lives

      John Wei, MD | Physician
    • How federal actions threaten vaccine policy and trust

      American College of Physicians | Conditions
    • Are we repeating the statin playbook with lipoprotein(a)?

      Larry Kaskel, MD | Conditions
    • When the clinic becomes the battlefield: Defending rural health care in the age of AI-driven attacks

      Holland Haynie, MD | Physician
    • mRNA post vaccination syndrome: Is it real?

      Harry Oken, MD | Conditions
    • The truth in medicine: Why connection matters most

      Ryan Nadelson, MD | Physician
  • Past 6 Months

    • The shocking risk every smart student faces when applying to medical school

      Curtis G. Graham, MD | Physician
    • COVID-19 was real: a doctor’s frontline account

      Randall S. Fong, MD | Conditions
    • Why so many doctors secretly feel like imposters

      Ryan Nadelson, MD | Physician
    • Confessions of a lipidologist in recovery: the infection we’ve ignored for 40 years

      Larry Kaskel, MD | Conditions
    • A physician employment agreement term that often tricks physicians

      Dennis Hursh, Esq | Finance
    • Why taxing remittances harms families and global health care

      Dalia Saha, MD | Finance
  • Recent Posts

    • The truth in medicine: Why connection matters most

      Ryan Nadelson, MD | Physician
    • New student loan caps could shut low-income students out of medicine

      Tom Phan, MD | Physician
    • Why trust and simplicity matter more than buzzwords in hospital AI

      Rafael Rolon Rivera, MD | Tech
    • Putting food allergy safety on the menu [PODCAST]

      The Podcast by KevinMD | Podcast
    • Why transgender health care needs urgent reform and inclusive practices

      Angela Rodriguez, MD | Conditions
    • Why “the best physicians” risk burnout and isolation

      Scott Abramson, MD | Physician

Subscribe to KevinMD and never miss a story!

Get free updates delivered free to your inbox.


Find jobs at
Careers by KevinMD.com

Search thousands of physician, PA, NP, and CRNA jobs now.

Learn more

View 2 Comments >

Founded in 2004 by Kevin Pho, MD, KevinMD.com is the web’s leading platform where physicians, advanced practitioners, nurses, medical students, and patients share their insight and tell their stories.

Social

  • Like on Facebook
  • Follow on Twitter
  • Connect on Linkedin
  • Subscribe on Youtube
  • Instagram

ADVERTISEMENT

ADVERTISEMENT

  • Most Popular

  • Past Week

    • Why primary care doctors are drowning in debt despite saving lives

      John Wei, MD | Physician
    • How federal actions threaten vaccine policy and trust

      American College of Physicians | Conditions
    • Are we repeating the statin playbook with lipoprotein(a)?

      Larry Kaskel, MD | Conditions
    • When the clinic becomes the battlefield: Defending rural health care in the age of AI-driven attacks

      Holland Haynie, MD | Physician
    • mRNA post vaccination syndrome: Is it real?

      Harry Oken, MD | Conditions
    • The truth in medicine: Why connection matters most

      Ryan Nadelson, MD | Physician
  • Past 6 Months

    • The shocking risk every smart student faces when applying to medical school

      Curtis G. Graham, MD | Physician
    • COVID-19 was real: a doctor’s frontline account

      Randall S. Fong, MD | Conditions
    • Why so many doctors secretly feel like imposters

      Ryan Nadelson, MD | Physician
    • Confessions of a lipidologist in recovery: the infection we’ve ignored for 40 years

      Larry Kaskel, MD | Conditions
    • A physician employment agreement term that often tricks physicians

      Dennis Hursh, Esq | Finance
    • Why taxing remittances harms families and global health care

      Dalia Saha, MD | Finance
  • Recent Posts

    • The truth in medicine: Why connection matters most

      Ryan Nadelson, MD | Physician
    • New student loan caps could shut low-income students out of medicine

      Tom Phan, MD | Physician
    • Why trust and simplicity matter more than buzzwords in hospital AI

      Rafael Rolon Rivera, MD | Tech
    • Putting food allergy safety on the menu [PODCAST]

      The Podcast by KevinMD | Podcast
    • Why transgender health care needs urgent reform and inclusive practices

      Angela Rodriguez, MD | Conditions
    • Why “the best physicians” risk burnout and isolation

      Scott Abramson, MD | Physician

MedPage Today Professional

An Everyday Health Property Medpage Today
  • Terms of Use | Disclaimer
  • Privacy Policy
  • DMCA Policy
All Content © KevinMD, LLC
Site by Outthink Group

Retrospective refusal of payment based upon final diagnosis compromises patients’ welfare
2 comments

Comments are moderated before they are published. Please read the comment policy.

Loading Comments...