HMOs Fail to Accurately Tell Patients of Emergency Rights

Strong ED Doctors Discover Lack of Compliance with N.Y. Law

October 13, 2003

          Many patients in New York are still unaware and misinformed out their basic rights to emergency hospital care, despite the passage of a law seven years ago that was designed to define emergency conditions and to correct a pattern of unjust denials of emergency coverage by health insurers.

            Charles L. Maddow, M.D., senior instructor, Emergency Medicine, University of Rochester Medical Center, and an attending physician in Strong Memorial Hospital’s ED, researched compliance to the law, called the New York Prudent Layperson Statute. He found widespread violations in the policies and instructions HMOs provide to their members:

            -- Although the law abolished any requirement that patients get prior authorization before seeking emergency care, 5 percent required preauthorization, 45 percent of HMOs still encourage pre-approval.

             -- 75 percent of health plans require members to notify their provider after receiving emergency care. Failure to do so may lead to denial of coverage.

             -- 40 percent of plans fail to accurately define what qualifies as an “emergency” in reference handbooks sent to their members. In fact, the plans often cite diagnoses rather than symptoms as examples of emergencies. This may be confusing for patients, Maddow says, as patients cannot accurately diagnose themselves. When denials are based on diagnosis, for example, a patient suffering chest pains who seeks emergency care might be denied coverage if a doctor finds that no heart attack occurred.

           -- 40 percent of insurance plans placed conditions on reimbursement, such as not allowing for more than one emergency room visit, or denying claims on retrospective reviews based at least in part on final diagnosis. Law prohibits this practice.

          The study is the first to examine compliance with the state law and to investigate loopholes. New York is one of 32 states in addition to the District of Columbia to have a prudent layperson statute. Maddow was invited to present his findings at the American College of Emergency Physicians Annual Scientific Assembly on Oct. 13, 2003, in Boston.

         “We found that often, patients are left to wonder whether to go to the emergency department and whether treatments will be covered for serious things such as chest pains, severe headaches, and symptoms that could indicate pneumonia,” Maddow says. “In some cases insurers used coercive language in their member handbooks, which violates the spirit of the law even if technically the insurer is in compliance.”

         New York’s PLS was enacted for several reasons: to more clearly define a medical emergency so that patients would understand when they should seek emergency care, to make sure patients would not be denied access to emergency care by their insurers, and to abolish the pre-authorization requirement. Maddow and his team analyzed the written text in the member handbooks for 22 of the 25 registered insurers in New York State, giving scrutiny to language that addressed emergency coverage. Three insurers declined to provide the information.

        “If widespread violations are occurring in New York,” Maddow says, “it is worth asking whether the same is true elsewhere. We would like to pursue this research on a national level.”

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