James Shoemaker: Why insurance denying coverage for an ER visit is illegal

Imagine that you are experiencing sudden, severe abdominal pain late at night.

Concerned that it could be appendicitis or another serious condition requiring immediate medical attention, you go to the nearest emergency department. Emergency department physicians stand ready 24/7/365 to treat all patients regardless of circumstance or ability to pay. After a thorough evaluation by the emergency physician, it turns out the pain was caused by a less urgent condition like indigestion or a muscle strain.

Months later, you receive a letter from your health insurance company stating that it will not cover your emergency room visit because, in retrospect, it determined the visit was not a true emergency. The insurance company argues that, based on the final diagnosis (such as indigestion), the visit did not meet the criteria for emergency care. The insurance company refuses to pay for your emergency visit.

In this scenario, the health insurance company might be violating the prudent layperson standard—or the PLP—which requires health insurance coverage based only on the symptoms the patient presented with at the time, not on the final diagnosis. Even though the initial symptoms (severe abdominal pain) prompted the visit to the emergency department, the insurance company’s decision not to cover the visit based on an eventual diagnosis could be considered a violation of this standard.

In fact, the PLP standard was put in place to protect patients from this very scenario. The standard was established because a patient (the layperson) should not be required to self-diagnose before seeking emergency medical care from a professional. The layperson should not be expected to know if the emergency visit will eventually qualify for payment from the insurance company—especially while in pain, short of breath or having other symptoms that would cause concern for any reasonable layperson.

Established in laws and regulations for years, the PLP standard is still one of the most important, patient-centric aspects of our health care system. When people are in pain or believe something is significantly “off,” they have the right to seek emergency care without concern that their commercial health plan will refuse to cover a reasonable visit after the fact based on medical information the patient couldn’t have known at the time.

Prudent layperson laws are not a “blank check” that force insurance plans to cover anything and everything. The PLP standard protects patients who are reasonably concerned about their health, who believe they might have an emergency and prudently seek professional help to take care of themselves.

Despite the multiple layers of federal and state laws and regulations designed to protect emergency care for patients, these assurances for patients and their physicians have been frequently undermined by managed care organizations. Instead of following the PLP standard that ensures patients seeking emergency care will be covered by their commercial health insurance, some MCOs are improperly limiting or denying coverage based on specific, final diagnoses.

These practices not only raise ethical concerns but clearly violate important federal and state regulations. By restricting coverage to predefined lists of diagnoses or symptoms, MCOs are not only disregarding long-standing patient protection laws but also jeopardizing an individual’s access to timely emergency medical attention.

We must collectively urge compliance with long-standing patient protections and ensure that down-coding practices do not hinder appropriate access to emergency medical care. By prioritizing patient welfare and ensuring compliance with established laws and regulations, we can re-establish a system where everyone in need receives the care they need during potential emergencies.•

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Shoemaker is a board-certified emergency physician and partner in Elite Emergency Physicians Inc. in north-central Indiana.