THE VALUED VOICE

In an interim final rule published in the federal register on July 13, the U.S. Department of Health and Human Services (HHS) has signaled it is watching insurer practices that would deny some patient claims for emergency services.
 
The provision, included in the agency’s rule related to out-of-network billing (“surprise medical bills”), specifies that insurers could not limit payment for emergency services solely based on the patient’s ultimate diagnosis. 
 
“That HHS specifically included this provision in the rule is significant and provides an important patient protection,” said WHA Senior Vice President, Public Policy Joanne Alig. 
 
At issue is whether an insurer should be able to determine after the fact that a patient should have sought care in an emergency room or somewhere else. Federal law and state law in Wisconsin require that insurers cover emergency services, and that in doing so apply an important patient protection known as the “prudent layperson standard.” The standard essentially says that if a reasonable person with an average knowledge of health and medicine thinks his or her health is in jeopardy based on his or her symptoms, then it is an emergency medical condition. 
 
In early June, United announced that it would retroactively review claims and deny some patient claims for emergency services, but after significant public attention, the company has since announced it would delay implementation at least until the end of the COVID public health emergency. The public health emergency was extended by the federal government just this week for an additional 90 days. The United policy is similar to one implemented by Anthem/Blue Cross Blue Shield in five states, excluding Wisconsin, which is being challenged in court. 
 
Comments on the rule are due to HHS by Sept. 13.