“Patients should not be forced to act as their own doctors and second guess themselves when they truly believe that they are having a medical emergency.”
"Despite federal law, private insurers are once again using tactics to prevent people from seeking care in the emergency room. On
"[W]e remain concerned that
The full letter, including a request for information on the Prudent Layperson standard, can be found below and at this link https://www.cardin.senate.gov/download/dol-hhs-prudent-layperson-standard-signed.
The Honorable
Secretary Secretary
Dear Secretary Azar and Secretary Acosta:
We write to request that your departments look into recent, potential Prudent Layperson Standard violations by certain health insurance issuers in multiple states. As you know, patients must be able to seek emergency care without fearing their health insurance company will require prior authorization or deny their claims. Patients should never be in a position of correctly diagnosing their specific emergency medical condition before seeking professional medical help.
From the 1980s-2000s, private insurers would routinely require prior authorization for emergency department (ED) visits or deny payments for visits that they deem inappropriate for that care setting, often based on retrospective review or discharge diagnoses. If an individual wanted insurance to cover an emergency treatment, the patient was expected to contact his or her insurer prior to the ED visit.
In response to these dangerous and unfair requirements, 47 states[2] and later in 1997,
Despite federal law, private insurers are once again using tactics to prevent people from seeking care in the emergency room. On
* A consumer was directed to the emergency room by a provider (including an ambulance provider)
* Services were provided to a consumer under the age 15
* The consumer's home address is >15 miles from an urgent care center
* The visit occurs
* The consumer is traveling out of state
* The consumer received any kind of surgery
* The consumer received IV fluids or IV medications
* The consumer received an MRI or CT scan
* The visit was billed as urgent care
* The ER visit is associated with an outpatient or inpatient admission[8]
While we appreciate
In light of these developments we request the following documents and a response to the following questions by
1.Please identify all of the guidance that HHS and DOL have issued on the Prudent Layperson Standard for Medicare, Medicaid Managed Care Plans, group health plans, and plans sold on the individual and group health insurance exchanges.
2. Regarding the Prudent Layperson Standard, CMS prohibits the use of codes (either symptoms or final diagnosis) for denying Medicare and Medicaid managed care plan claims because the agency believes there is no way a list can capture every scenario that could indicate an emergency medical condition under the Balanced Budget Act of 1997 provisions. However, commercial plans have been able to use CPT codes to flag claims that are later determined to be an "avoidable emergency" and not covered by the insurance company. Is there a reason for this discrepancy? Please explain.
3.
* If HHS and/or DOL believes that
* If HHS and/or DOL conclude that any or all provisions of
* If HHS and/or DOL have concluded that any or all provisions of
4. In addition to
5. Is CMS aware of other health insurance issuers with Medicare and Medicaid managed care contracts implementing similar policies that discourage patients from seeking emergency medical care in emergency departments? If so, please disclose those group health plans and/or health insurance issuers.
6. Has HHS and/or DOL received complaints from state regulators about health insurer issuers offering group health coverage potentially violating the Prudent Layperson Standard? If so, please provide a copy of all communications, including e-mail related to this topic.
7. Has HHS and/or DOL received complaints about group health plans potentially violating the Prudent Layperson Standard? If so, please provide a copy of all communications, including e-mail related to this topic.
8. Has CMS received complaints about insurance issuers with Medicare and Medicaid managed care contracts potentially violating the Prudent Layperson Standard? If so, please provide a copy of all communications, including e-mail related to this topic.
[1] Hiltzik, Michael,
[2] All except MS, NH, WY.
[3] P.L. 105-33; 42 C.F.R..[Sec.] 438.114.
[4]P.L. 111-148; 29 C.F.R..[Sec.]2590.715-2719A(b)(4)(i).
[5] P.L. 111-148; 29 C.F.R. [Sec.]2590.715-2719A..
[6] Hiltzik, Michael,
[7] Id.
[8] Liss Samantha,
Read this original document at: https://www.cardin.senate.gov/newsroom/press/release/cardin-mccaskill-call-on-hhs-dol-to-uphold-prudent-layperson-standards-for-emergency-room-health-coverage
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