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Last updated on April 20, 2014 at 0:02 EDT

Washington State Changes Course – Upholds Prudent Layperson Standard for Medicaid Emergency Patients

April 2, 2012

WASHINGTON, April 2, 2012 /PRNewswire-USNewswire/ — Washington Gov. Chris Gregoire has suspended the April 1 implementation of a Zero Tolerance Policy that would have denied payments for treating Medicaid emergency patients. Denials would have been based on a list of 500 final diagnoses the state has deemed to be nonurgent.

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The nation’s emergency physicians today applauded the leadership of the governor, saying her decision sends a clear message to all health plans to support the prudent layperson standard, which requires coverage based on a patient’s symptoms. David Seaberg, president of the American College of Emergency Physicians (ACEP) said this is important because many patients have the symptoms of a medical emergency, and it’s not possible to diagnose their conditions until medical exams and tests are completed.

“We commend Gov. Gregoire for recognizing the flaws in this plan and for not only standing up for Medicaid patients but for all patients,” said Dr. Seaberg. “The proposed list of non-emergent diagnoses puts patients in danger and unfairly targets the poor and those in most need of care. If this plan had gone into effect, other states might have followed. Stopping this plan has been a top priority for ACEP and the Emergency Medicine Action Fund.”

The Emergency Medicine Action Fund is a coalition of organizations, practitioners, and stakeholders created to respond to the challenge of health care reform across the acute care continuum. Its contributors committed up to $100,000 to the Washington Chapter of ACEP for litigation efforts and another $55,000 for policy analysis and health care research showing the HCA proposal would not have been safe for patients with a large number of urgent or emergent conditions.

“The breakthrough of the leaders in Washington ACEP reflects on the ability of the EM Action Fund to respond rapidly to legal and regulatory challenges facing emergency physicians,” said Dr. Wes Fields, Chair of the EM Action Fund. “The nation’s emergency departments provide timely access to first-contact care that is lacking in many communities for Medicaid beneficiaries, and we’re glad that reason has prevailed in Washington State.”

The Washington Health Care Authority (HCA) originally proposed limiting Medicaid patients to three emergency visits that the state determined were not emergencies. But as a legal battle got underway, the state revised their plans and proposed a Zero Tolerance Policy that would have denied coverage for all emergency visits made by Medicaid patients with nonurgent diagnoses, such as sprains, which could have been broken bones.

“We are excited about this development as it reflects strongly on the likelihood of our success and recognition of the work of the collaborative efforts of the Emergency Medicine Action Fund, Washington ACEP, the Washington State Hospital Association, the Washington State Medical Association, and many others,” said Dr. Nathan Schlicher, Associate Medical Director at St. Joseph Medical Center in Tacoma, WA and Legislative Affairs Chairman for the Washington ACEP Chapter. “We hope that the legislature will close business this week, include in their work our alternative plan that is already drafted into the house budget plan, and let us get back to the work of improving the delivery of care.”

The Washington Chapter of ACEP argued the state’s plan is in direct violation of the national prudent layperson standard, which requires health insurance plans to base coverage of emergency care on a patient’s symptoms and not their final diagnoses.

“Patients should never be forced to self-diagnose themselves out of fear that their emergency visit won’t be covered,” said Dr. Seaberg.

Washington’s physician-authored alternative plan includes strategies such as requiring timely follow-up by primary care physicians, creating a real-time database to track emergency visits and closer case management. This could serve as a resource for dozens of other states considering similar plans to deny Medicaid payments based on final diagnoses.

The prudent layperson standard requires health plans to cover visits to emergency departments based on an average person’s belief that he or she may be suffering a medical emergency due to the symptoms he or she is experiencing, not a final diagnosis. It is designed to protect patients who experience the symptoms of a medical emergency but who, after a medical examination and testing by a trained professional, are diagnosed with an acute care or non-emergent medical condition.

This standard was codified into the national health care reform law, the Affordable Care Act, in 2010 and was included in the Medicare Balanced Budget Act of 1997. Other states, including California, Iowa, Florida, Illinois, New Hampshire and Tennessee have been seeking to cut back on Medicaid because of the financial crisis — but at a time when more people are needing Medicaid because they have lost their jobs and health insurance.

ACEP is the national medical specialty society representing emergency medicine. ACEP is committed to advancing emergency care through continuing education, research and public education. Headquartered in Dallas, Texas, ACEP has 53 chapters representing each state, as well as Puerto Rico and the District of Columbia. A Government Services Chapter represents emergency physicians employed by military branches and other government agencies.

Follow ACEP on Twitter — www.twitter.com/emergencydocs

SOURCE American College of Emergency Physicians (ACEP)


Source: PR Newswire