Brault President and CEO Joins ACEP Frontline Podcast to Discuss “The Prudent Layperson Standard” and Current Payer Behaviors That Seem to Value Record Profits over Patient Lives

Business Wire

Andrea Brault, MD, MMM, FACEP and host Dr. Ryan Stanton discuss the history of PLPS, how payers are gaming the system to deny coverage for emergency care – and what providers can do to fight back!

SAN DIMAS, Calif.--(BUSINESS WIRE)-- Dr. Andrea Brault recently joined the ACEP Frontline podcast to discuss the dangerous game of payment denials that’s being fueled by some of the country’s largest insurers. Hosted by Dr. Ryan Stanton, ACEP Frontline features in-depth conversations on the hottest topics in emergency medicine and critical care.

Episode description: Host Dr. Ryan Stanton and his guest Dr. Andrea Brault discuss “The Prudent Layperson Standard” and how payers are trying to change the game. More and more the patient is left to determine if they are having a medical emergency. Patients are afraid they’ll be left with the bill when the insurance company threatens to deny claims and some of these patients are suffering harm and dire outcomes because they don’t go to the ED.

Listen to the full podcast: https://www.brault.us/blog/2019/01/08/acep-frontline-interview-insurance-gaps-and-payment-games-plps/

The cost of medical services, especially in the emergency department, has long been a subject of debate and scrutiny. And, again, we’re seeing the battle heat up – with commercial payers launching coordinated efforts to point the finger at physicians and the high cost of care; while providers struggle to bring attention to predatory payer practices that are at the core of this national debate.

“What we’re seeing now is payers trying to re-interpret the Prudent Layperson Standard (PLPS),” explains Dr. Brault. “Instead of determining an emergent need based on presenting symptoms, payers like Blue Cross Blue Shield, Anthem, and others are using the discharge diagnosis to make their payment determination, and this is expressly forbidden. It was forbidden at the time of implementation in 1997. It was forbidden through the Federal Register in 2002 and again reinforced through the Federal Register in 2016.”

So, what does it all mean?

Despite several studies in medical literature demonstrating no reliable way to verify an emergent need based on final diagnosis, or to predict an emergent need based on presenting symptoms, commercial payers continue to push the boundaries of what they can get away with in terms of payment denials.

“This ongoing battle has led to coordinated PR efforts to publish media stories, with the presumable aim of deterring the use of emergency departments. And, for some patients, it has resulted in massive bills due to payment denials when they seek care for a condition that the payer deems non-emergent,” continued Dr. Brault.

Listen to the full podcast for a deeper analysis on bad payer behaviors and learn how you can help combat their attacks against The Prudent Layperson Standard.

ABOUT BRAULT

Brault is a clinical intelligence partner for independent physician groups and hospitals in 18 states, with intelligent practice solutions for Practice Management and Revenue Optimization. The company manages more than 4 Million annual patient visits and is led by President and Chief Executive Officer, Andrea Brault MD, MMM, FACEP – a board-certified emergency physician and current Chair of EDPMA.

Learn more at www.Brault.us.