State insurance commissioners are considering model legislation that would require insurers and managed-care organizations to pay for emergency department care based on symptoms, not on final diagnosis.
The model legislation, if adopted by the states, would limit insurers' ability to deny coverage for emergency services because the final diagnosis of an emergency room visit did not merit such care.
Insurers are resisting the National Association of Insurance Commissioners' action, saying it is unnecessary as long as health plans appropriately define what an emergency is.
The NAIC's action falls under its work on health plan accountability, which seeks uniform state laws and regulations on managed-care and insurance contracting practices, quality assessment, utilization review, credentialing and related issues.
The NAIC's working group on health plan accountability hopes to wrap up its work later this year.
It would follow the lead of three states that already have passed standards requiring insurers and managed-care groups to pay for services provided that a "prudent layperson" would believe that symptoms required emergency care.
Cal Chaney, associate executive director for policy at the American College of Emergency Physicians, said 25 other states introduced similar legislation in January.
The NAIC's health plan accountability work group decided to move toward the prudent-layperson standard at a meeting in San Antonio last December and rebuffed efforts to remove it at a meeting earlier this month in Kansas City.
Chaney said such a standard is necessary to curb the "aggressive denial mode" of insurers and health plans.
"It takes out of the normal person's hands the need to make a clinical or quasi-clinical decision about their health" when deciding whether to go to an emergency room, Chaney said.
Lynne Fritter, counsel for the Health Insurance Association of America, said studies have shown that most of the denials of emergency-room coverage are appropriate, but inappropriate emergency-room care still adds billions in unnecessary healthcare costs.
Furthermore, she said, if health plans clearly define to their insured population what constitutes an emergency, such regulation is unnecessary.