Blog Post

By Rhonda Sandel, Board President

Texas Association of Freestanding Emergency Centers (TAFEC)

Learn More About The Prudent Layperson Standard

Texas, Defending the Prudent Layperson Standard is a Matter of Life and Death

By Rhonda Sandel, Board President, Texas Association of Freestanding Emergency Centers (TAFEC)

When the Texas House Committee on Insurance meets this week to discuss Rep. Julie Johnson’s bill (HB 1832) aimed at defending the Prudent Layperson Standard, a lot will be on the line for my fellow Texans. Also note that there is a companion bill from Sen. Donna Campbell (SB 1282) that seeks to accomplish the same patient protections.

These consumer advocates believe in your rights and are working to ensure that you are protected from overzealous insurance company executives, who often place profits above the healthcare outcome that’s best for you. Cost should never dictate whether or not your medical rights are worth protecting.

A Refresher: What Exactly 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 require prior authorization for emergency department visits or deny payments for visits that they deemed inappropriate for that care setting, often based on a retrospective review or discharge diagnosis. If an individual wanted insurance to cover an emergency treatment, the patient was expected to contact his or her insurer for approval prior to an ER visit.

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

Essentially, 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 that 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.

Texas adopted this Prudent Layperson Standard definition in 1997 through Senate Bill 385, Section 1301.155.

Why is this issue so important to everyday consumers here in Texas and across the country?

Consider the Numbers

Studies in the Journal of the American Medical Association have shown that there is a 90 percent overlap in the kinds of symptoms found in patients suffering from emergency and non-emergency conditions. Even emergency room physicians will tell you that without a proper patient work-up, they would not be comfortable judging on symptoms alone whether or not a patient is having a medical emergency.

Pushback from Big Insurance

Have you ever gotten the sense from your health insurance company that it’s trying to prevent you from fully utilizing the benefits of the coverage you’re paying for? If so, you’re not alone.

The reality is this: certain insurance companies are now forcing reasonable people to make a decision—do I seek potentially life-saving care that I think I need (but might cause me financial ruin if I turn out to be wrong) or do I just wait it out and hope that whatever health emergency I think I’m facing soon passes?

Trust Your Gut

Clearly, the answer should always be: if you or a loved one thinks they are experiencing a medical emergency, immediately go to the nearest ER for treatment. Your insurance company doesn’t get to decide whether or not you or a loved one is worth it.

Bottom line, if you think you are having a medical emergency and you go to the ER seeking care, your visit should always be covered by your health insurance plan.

Where to Go to Learn More

Fortunately for Texas patients, your ER doctors and other medical personnel are standing up for you and defending your right to have your ER visit covered in the event of a medical emergency. In fact, with the 86th Legislative Session halfway completed, you have a growing online resource to turn to—MyEmergencyMyChoice. We are hearing from many of you about your patient experiences—your stories have an important impact with both legislators and the media.

This week’s important House Insurance Committee hearing will give Texas legislators an opportunity to be further educated on what’s at stake if health insurance companies are permitted to continue trampling on the rights of Texans seeking life-saving ER care.