Kansas Insurance Commissioner Proposes Emergency Access Bill
While federal lawmakers prepare to consider establishing the "prudent layperson" standard for defining emergencies, lawmakers in Kansas are also taking a second look at regulating managed care coverage of emergency services.
As part of a comprehensive package of bills concerning the managed care industry, State Insurance Commissioner Kathleen Sebelius introduced a measure in the state senate in February mandating reimbursement for emergency medical services given to patients who meet the "prudent layperson" standard.
"We have received a number of complaints about payment for emergency services being turned down," says Tom Wilder, Director of Government and Public Affairs for the Kansas State Insurance Department.
In response to the complaints, the department drafted the "Emergency Room Services Payment Act," which would require any health plan in the state to cover emergency services "necessary to screen and stabilize" a patient.
The bill would:
• prohibit the plan from requiring prior authorization if "a prudent layperson acting reasonably" believes an emergency medical condition exists;
• require the plan to cover emergency services if the carrier’s participating health provider authorized treatment in the ED;
• prohibit the carrier from retrospectively denying coverage or reducing the amount of reimbursement after care in the department is authorized; and
• provide access to an authorized representative 24 hours a day, seven days a week.
"We consider this a consumer issue to give people a little bit of flexibility in trying to seek care," says Kevin Koch, MD, FACEP, President of the Kansas chapter of the American College of Emergency Physicians and Vice Chairman of the Emergency Department at Shawnee Mission Medical Center in Shawnee Mission, KS.
The chapter was the driving force behind a similar bill that was introduced last year but failed to pass, Koch says. He is encouraged that this bill has been initiated by the Insurance Department and has their support.
"What worries me is that we are already starting to see this "once burned, twice shy" phenomenon, where people came in for something and their care was denied, and then they develop symptoms that really are genuine and dangerous and they are reluctant to come in because they are afraid of being stuck with the bill," he says.
Health plans that deny payment based on a final diagnosis that does not meet their definition of an emergency medical condition is something he sees almost every day, says Koch. He also spends at least two hours a week writing appeals for patients about the bona fide nature of their ED visits so they can appeal their plan’s decisions.
"The classic example, and I have a complaint on my desk right now, is chest pain," says Koch. "A man came in with chest pain, and he had a number of risk factors for having genuine heart trouble. The initial tests did not show a definite heart attack, but they were certainly suggestive of unstable angina.
"The prudent thing to do is admit someone and check heart enzymes and do some kind of diagnostic evaluation," he says. "We did a treadmill test the next morning. Turns out his treadmill test was negative and he was dismissed from the hospital with a diagnosis of esophagitisbasically, heartburn."
The man’s insurance company is now saying it will not pay for the treatment because heartburn is not an emergency medical condition, Koch says.
"Doing a proper evaluation of chest pain in a man with risk factors for heart disease, I think, is an appropriate thing," he says. "The next thing it will be is you have a breast biopsy performed on a woman and, if it’s cancer, they pay, and if it’s not, they won’t. That’s where we are headed."
MCOs and HMOs have opposed the legislation, saying it limits their cost-effectiveness and unfairly groups them with unscrupulous practitioners who are causing the problem, says Koch.
Faced with a "hot potato" last year, the House committee chairman let the bill die, Koch says. He is not much more optimistic for the measure’s chances this year.
"It’s hard to read what a Legislature will do," Wilder says. "Right now, it has been introduced and is scheduled for a committee hearing."
When asked about the bill in February, State Rep. Tom Bradley, chairman of the House insurance committee, and state Sen. Don Steffas, chairman of the Senate insurance committee, both said that they had not yet had a chance to become familiar with the proposal, and neither would predict its chances of even making it to the floor of the full Senate or House.
If the bill does become law, it will then be up to the health plans to educate their members about when to go to the ED, says Koch.
"I think the insurance companies are obliged to educate their members well about what constitutes an emergency," says Koch. "But, when their people come in, [they should also] cover it."
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