The Law is on Your Side


Post by Kevin Herrington, MBA FACHE, Altus Emergency Centers

The policy is so outrageous and dangerous to the public, that it has even reached the United States Senate. As reported by CBS News, Claire McCaskill, while a Senator from Missouri, sent a letter to both the U.S. Department of Health and Human Services and the Department of Labor requesting that they investigate whether certain health insurers had violated the Prudent Layperson Standard.

The Prudent Layperson Standard was added to group and individual health insurance plans in 2010, and it requires health insurance companies to cover emergency room visits based on symptoms and not the final diagnosis.

In our state, the Texas Department of Insurance (TDI) requires insurance companies to pay emergency facilities the same way they would bill a hospital facility, which is part of an insured patient’s “in-network.” In other words, your insurance company should cover the same amount regardless of what type of emergency facility you visit; they cannot legally provide you with a lower benefit level.

The Patient Protection and Affordable Care Act also added numerous patient protections, most notably, it requires health plans covering emergency services to provide such coverage without the need for prior authorization.

Furthermore, health plans are required to pay for emergency visits for medical situations in which an average layperson believes his or her health is threatened. The final diagnosis should not in any way influence whether or not the insurer pays for the emergency room visit, and insurance companies cannot legally apply the claim towards “out-of-network” benefits.

Kevin Herrington began as an Administrator for Altus in early 2007, and has successfully managed several facilities since construction. With 20 years of experience in healthcare, Kevin currently oversees operations, as well as the development and direction of all future projects. Kevin currently holds the status of Fellow with the American College of Healthcare Executives, and is a member of the American Society of Clinical Pathologists.

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