LD 1155,  An Act To Protect Patients and the Prudent Layperson Standard, was introduced by Speaker Gideon earlier this month

AUGUSTA –  Speaker of the House Sara Gideon (D-Freeport) testified today in support of  LD 1155, “An Act To Protect Patients and the Prudent Layperson Standard.” Gideon introduced the legislation earlier this month. LD 1155 strengthens existing law preventing  insurance companies from denying emergency room claims by requiring these companies to cover visits based on the patient’s presenting symptoms, not the final diagnosis. It also strengthens existing law prohibiting a carrier from requiring prior medical authorization for emergency services.

Speaker Gideon released the following statement:

“Insurance companies are essentially forcing patients to either play a role in determining their own medical condition or risk that the cost of the care won’t be covered. This is a choice no Mainer should have to make—especially in the chaotic, terrifying moments of a medical emergency when they should be focusing on their wellbeing.

“We must proactively strengthen these common sense regulations before Mainers are forced to self-diagnose when making the already difficult decision to go to the emergency room. It’s our duty to protect the health of all Mainers—passing LD 1155 and strengthening Maine law will do just that.”

In several states, insurance companies have been warning policy holders that if their emergency department visit results in a diagnosis for something that the insurer doesn’t think was an emergency, the insurer will deny  or reduce the payment of the claim. This leaves the patient responsible for the bill.

LD 1155 faces additional votes at a later date in the Health Coverage, Insurance and Financial Services Committee in the coming weeks.

Below is Speaker Gideon’s written testimony in full.

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Senator Sanborn, Representative Tepler and distinguished members of the Joint Standing Committee on Health Coverage, Insurance, and Financial Services, I am Sara Gideon, and I represent the town of Freeport and part of Pownal. I also have the distinct honor of serving as the Speaker of the Maine House. I’m here today to present my bill, LD 1155, An Act To Protect Patients and the Prudent Layperson Standard.

This bill does three crucial things:

  1. It prevents insurance companies from denying emergency department claims, or reducing payment of such claims, by requiring companies to cover visits based on the patient’s presenting symptoms, not the final diagnosis.
  2. It prohibits a carrier from requiring prior medical authorization for emergency services; and
  3. It requires that reviews of benefit determinations for emergency services be conducted by a clinical peer that is board certified in the same specialty and licensed to practice in Maine.

I submitted this bill because within the last few years, insurance companies in several states, including New Hampshire, have begun denying coverage, or drastically limiting payment, for emergency department visits when the patient’s final diagnosis is determined to be “non-emergent.”

This practice discourages patients from going to the emergency department when they have symptoms that could indicate an emergency, resulting in patients not receiving the care they need, not seeking emergency care in the future, discrimination against patients with lower health literacy, and conflicts with goals for access to care.  As many policyholders are unaware of their right to appeal any claim rejection, this practice only contributes to ballooning medical debt.

Oftentimes, patients experiencing “true emergencies” have similar initial symptoms to those patients that have non-emergent conditions. As we all know, it is often difficult for emergency physicians, much less patients, to know based on a patient’s initial symptoms whether their condition will ultimately end up being emergent. These insurance companies are essentially forcing patients to either play a role in determining their own medical condition or be forced to pay.  In Georgia, one insurance company announced this policy change using the threat of “Save the ER for emergencies, or you’ll be responsible for the cost.” This is a choice no Mainer should have to make – especially in the chaotic, terrifying moments of a medical emergency when they should be focusing on their wellbeing.

The Georgia House of Representatives did a report on this practice and compiled some compelling examples of patients that have had their coverage denied or reduced because of these harmful policies. Here are some highlights of the report:

  • “A 62-year-old male has an uncontrolled nose bleed where compression is not working. He is on anticoagulants, which make his nosebleed potentially life-threatening if it’s not quickly and correctly controlled. In the ER, aggressive treatment is initiated and he is admitted to the hospital by the surgeon for further control and monitoring. Payment denied. Services not deemed necessary.”
  • “A 45-year-old male comes to the ER requesting help. It is discovered that he is actually in advanced stages of acute alcohol withdrawal (which has high mortality if untreated) and is appropriately treated. Payment denied. Services not deemed necessary.”
  • “A 43-year-old female with a history of prior clots in her lungs developed calf pain and shortness of breath a few weeks after undergoing surgery. She is emergently and thoroughly evaluated, but no evidence of a clot is found and she is, gratefully, discharged. Payment denied. Services not deemed necessary.”

The prudent layperson standard requires insurance companies to cover the costs of emergency department visits based on if a patient’s symptoms would lead a prudent layperson, possessing an average knowledge of medicine and health, to believe emergency care is necessary. The prudent layperson standard exists in federal and state law, but, as I’ve been discussing, we are seeing insurance companies begin to violate it. LD 1155 would strengthen it in state law to ensure Mainers are protected and it would clarify what the prudent layperson standard means. By prohibiting requiring prior authorization and establishing clear review standards, LD 1155 further protects Maine consumers from unfair billing practices.

I am deeply troubled by these practices and am concerned that insurance companies will begin to enact these policies here in Maine. Insurance companies’ requiring their patients to act as medical professionals when experiencing urgent medical events is unfair, untenable, and puts patients at risk. We must proactively strengthen these common sense regulations before Mainers are forced to self-diagnose when making the already difficult decision to go to the emergency room.

I believe it’s our duty to protect the health of all Mainers. Strengthening the prudent layperson standard in Maine law will do just that. I’m confident the committee will consider these matters carefully, and I respectfully ask that you support LD 1155. It is my understanding that the Bureau of Insurance is going to recommend some technical fixes to the bill, and I would be happy to work them on an amendment.

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