MD providers protest HMOs' disregard for prudent layperson law
MD providers protest HMOs' disregard for prudent layperson law
Annapolis, MD-Frustrated with a continuing series of payment denials by health insurers, emergency physicians representing 13 Maryland hospitals have filed a formal complaint with the state insurance commissioner.
The providers allege that health maintenance organizations (HMOs) doing business in Maryland are engaged in an illegal pattern of reimbursement denials in violation of a 1993 state law that established a prudent layperson standard for emergency department services.
Providers have submitted specific instances in which health plan denials violated provisions of the state's prudent layperson law. However, the Maryland Insurance Administration (MIA), which regulates the state's HMOs, could be laying the groundwork for a protracted debate over whether the claims denials actually constitute a violation of the law.
The agency has asked for specific evidence of each denial presented in terms of each patient's chart and claim number. Larry Linder, MD, president of the Maryland chapter of the American College of Emergency Physicians has advised state officials to consider each case individually. "Underlying medical conditions and environmental factors may greatly influence whether a presenting complaint is a medical emergency for a particular patient," Linder wrote in a letter to the MIA.
He urged state officials to consult with emergency physicians with expertise in coding and billing to help in evaluating patient cases according to the prudent layperson standard.
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