Prudent Layperson Standard Legislation

Prudent Layperson Standard Legislation

POSTED IN: Forum Topic,

The 2018 Missouri Legislative Session ended last Friday, and MOCEP is pleased to say we were able to get some key legislation passed for emergency medicine. 

You likely have heard of the battle MOCEP has been fighting for nearly a year against an insurance company that has been denying emergency room visit claims that were determined to be non-emergent based on the diagnosis. This was a violation of the Prudent Layperson Standard and despite many conversations with the insurance company, MOCEP had to take this issue to the legislature to protect our patients. 

Senate Bill 982 carried the language that will uphold the Prudent Layperson Standard in Missouri. The language requires insurers to reimburse emergency room claims based on the initial symptoms, not the patient’s final diagnosis, and outlines a claim review process for post-stabilization services in the ER. It also states that the ER physician is the sole determinator of when the patient is stabilized under the prudent layperson standard.

Senate Bill 982 also includes new state law that requires insurance companies to pay the facility and/or physician directly for care provided to out-of-network patients when the insurer has given the patient authorization to seek out-of-network care. 

Balance billing was added to this bill near the end of session and we are currently reviewing this language with the ACEP office and will provide more updates soon.