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The Prudent Layperson Standard Revealed

My Emergency My Choice: The Prudent Layperson Standard Revealed

On your way to dinner with a friend, you start to feel a numbness in your leg and a slight pain in your back. You shrug it off and decide to continue on to your dinner plans. But, once you’re there, the pain doesn’t subside. In fact, it starts to get substantially worse. You decide you will just go home, take some pain medication, and sleep it off. You can’t afford a visit to the emergency room right now. This actually happened to Brian, a real patient of our MEMC Board member and Experienced ER Physician Eric McLaughlin, MD FACEP. Had Brian decided to return home — like thousands of people do everyday, he would not be here to tell his story. His symptoms were mild, but his final diagnosis was a life-threatening blood clot in his spine. This diagnosis is very rare, but the symptoms presented are extremely common. Here is Brian’s story:

How do you know for sure if the numbness in your leg is just a pinched nerve or a stroke? Should you be held accountable if you seek emergency care and the final diagnosis comes back as a minor condition? All of these questions and more will be revealed…

What is The Prudent Layperson Standard?

The Prudent Layperson Standard (PLS) grew out of the insurance environment of the early 1980s. In 1986, the U.S. Congress enacted the Emergency Medical Treatment and Labor Act (EMTALA), setting the standard that hospitals must provide care to anyone needing emergency treatment.

However, private insurers routinely would deny payments for emergency room visits that they deemed non-emergent. This was often based on a retrospective review of the final diagnosis.

This meant that anyone who visited the ER complaining of numbness in their legs or chest pain that were later determined to be something other than a life-threatening condition, could be responsible for 100 percent of the cost of treatment.

This forced patients to contact their insurance company during a moment of crisis to essentially ask whether or not they should visit the ER—a policy which clearly placed the health and wellbeing of the individual in jeopardy.

In response to such potentially dangerous and unfair requirements, many states enacted Prudent Layperson Standard laws, with Congress enacting the Prudent Layperson Standard in 1997

Before we dive any further, you should know that if you believe you are having an emergency, you should seek care at the closest licensed emergency medical facility. Brian’s story above perfectly outlines the real world scenarios and questions patients have when they believe they might be having an emergency. 

Disincentivizing patients from visiting an emergency center is a harmful and possibly deadly practice. Removing uncertainty from patients’ minds when seeking care is why the Prudent Layperson Standard was created. So, what does the document actually say?

Now that you are anxiously awaiting the possibility of a future bill you think to yourself, why would I receive this? Good question. Insurers would like you to believe that they are simply outlining all of the charges incurred from your treatment. But these documents are really used as a scare tactic by the insurance companies to make patients believe they will receive a bill in the future. Or even more nefariously, make patients second guess seeking out emergency care in the future. On top of the lack of value this information presents to the patient, these documents are confusing. So confusing that most major insurers have pages and documents outlining what these documents are for and how to read them.

The Prudent Layperson Standard states:

“The term ‘emergency medical condition’ means a medical condition manifesting itself by acute symptoms of sufficient severity (including severe pain) such that a prudent layperson, who possesses an average knowledge of health and medicine, could reasonably expect the absence of immediate medical attention to result in:

  • Placing the health of the individual (or, in the case of a pregnant woman, the health of the woman or her unborn child) in serious jeopardy,
  • Serious impairment to bodily functions, or
  • Severe dysfunction of any bodily organ or part, [or]
  • Serious disfigurement”

What does this mean to you, the patient?

Here is our Board member, Dr. McLaughlin revealing the details of the Prudent Layperson Standard and what it means for you:

As Dr. McLaughlin states, “[It’s] the Prudent Layperson[‘s right] to come to the emergency room whenever they think something isn’t right, and let me [a licensed emergency doctor] determine if they have an emergency.” To explicitly reveal the intricacies and how it affects you, here are three core elements the Prudent Layperson Standard outlines: 

  • It is your right as a prudent layperson to seek emergency care when you believe you are having an emergency. 
  • You cannot be held responsible by your insurance company if your diagnosis comes back as non-emergent after arriving at an emergency center with symptoms that you deem to be severe or serious.
  • You should never be scared or intimidated by anyone, including your insurance company, to seek treatment when you believe you are having an emergency!

As Dr. McLaughlin puts it
“The Disincentivization, or the penalties that patients perceive they may get. I worry, as an emergency physician, that by the time they do get here, it will be too late.” 

Don’t ignore your body’s warning signs, trust your instincts and get emergency care when you think you need it, after all it is your emergency and your choice.

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