An Ohio Republican state representative introduced legislation to protect patients from insurance companies denying or reducing reimbursement for emergency service claims.
House Bill (HB) 99, sponsored by State Representative Susan Manchester (R-Waynesfield), will require insurers to conduct an emergency physician review of a claim before denying or reducing reimbursement for an emergency services claim and prohibit insurers from denying coverage of emergency claim based solely on the final diagnosis of the patient.
A federal law known as EMTALA (the Emergency Medical Treatment and Labor Act) requires that any patient who presents to an emergency department receive a medical screening exam and any care needed to stabilize that emergency. This care is provided regardless of insurance status or ability to pay.
Ohio currently has a prudent layperson standard law. This means that if a person with average medical knowledge believes they have an emergency medical condition, the insurance should consider that visit to the emergency department a medical emergency.
According to Manchester, some insurances are denying legitimate insurance claims of patients who sought care in the emergency department if, after the medical screening, they determine that the patient’s condition is non-emergent.
“This retroactive denial by the insurance company results in a “surprise bill” for the patient and a “surprise lack of coverage” resulting in debt to patients and, if they can’t afford to pay, a loss to hospitals and clinicians. This is particularly concerning to safety net hospitals that can ill afford these losses. What is especially vexing is that these patients were not uninsured. They were denied their appropriate coverage,” Manchester said.
Manchester (pictured above) claimed that HB 99 will strengthen and clarify the existing prudent layperson standard and stresses that it applies regardless of the final or presumptive diagnosis.
Manchester said that this legislation is necessary as it is dangerous for Ohioans to be put in a position where they would try and self-diagnose a medical condition for fear of being stuck with a bill, even though they have insurance.
“Many conditions such as stroke, heart attack, and brain aneurysm, are time-sensitive diagnoses. The prudent layperson standard was developed to protect our patients, to ensure that their health would never be put in jeopardy because of a disincentive to seek potentially lifesaving care in the event that a patient has an acute issue. Patients should not be expected to try and determine what the cause of their symptoms are before deciding whether to seek emergency care,” Manchester said.
According to Manchester, HB 99 aims to ensure that Ohioans who access the emergency department when they feel they need immediate medical attention will not have their insurance coverage denied based on an algorithm, but instead, insurers will review the patient’s claim before making a determination.
HB 99 is currently under review by the Ohio House Insurance Committee.
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Hannah Poling is a lead reporter at The Ohio Star and The Star News Network. Follow Hannah on Twitter @HannahPoling1. Email tips to [email protected]
Photo “Susan Manchester” by The Ohio House of Representatives. Background Photo “Ambulance” by camilo jimenez.
