A study billed as the first to review enforcement of "prudent layperson" laws for emergency room visits finds that all HMOs studied in New York state violate some aspect of the law.
Besides New York, the Medicare and Medicaid programs and about 30 states have adopted the prudent layperson standard, which requires health plans to pay for an ER visit when the patient believes there was an emergency, even when none took place.
Authors of the new study, in the October issue of the Annals of Emergency Medicine, published by the American College of Emergency Physicians, say that to their knowledge no one has studied health plans' compliance with prudent layperson laws.
Reviewing policy information from 20 New York plans, researchers found that not one plan informed enrollees of their right to emergency care under the state's 7-year-old law.
In fact, they report that one plan actually required, and almost half encouraged, prior authorization for all ER visits.
"Clearly, increased enforcement is necessary to ensure that health plan policies do not hamper a patient's timely access to emergency medical care," says the study's lead investigator, Charles Maddow, M.D., an emergency physician at the University of Rochester School of Medicine and Dentistry.
Specifically, the study finds that in plans' enrollee information:
- Two plans did not define emergency services, and eight plans gave diagnoses rather than symptoms as examples of emergencies.
- Fifteen plans required that members contact their primary care provider after emergency care, and three would deny payment without such contact, while the remaining 12 left this issue unspecified.
- Eight plans placed conditions on reimbursement. One covered only the first visit for a clinical condition and the other seven conducted retrospective reviews based at least in part on final diagnosis.
- Three plans encouraged enrollees to go to an affiliated, rather than the closest, ER.