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Prudent Layperson's law
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Re: Prudent Layperson's law
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Steve Verno
Re: Prudent Layperson's law
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Apr 11 05 12:54 PM
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The prudent layperson is a definition in the federal law that defines an emergent medical condition. The law generally requires that the urgency of a patient's condition be judged based on presenting symptoms, and that the symptoms reasonably warrant immediate attention, from the perspective of an ordinary person. The reason for this was because HMOs were using a final diagnosis to deny a claim based on whether or not the condition was emergent.
I believe your situation is based on the fact that the HMO is not paying you 100% of billed charges as a non-par provider. This has nothing to do with the prudent layperson definition of an emergency.
The payment of the claim is based on 2 things. (1) Is the plan under ERISA or State law and (2) are you contracted or not contracted. In your case, you are not contracted, therefore the only question that pertains here is, is the plan under ERISA or State law. If the plan is under State Law, then you need to see what your state says about reimbursing non-par providers. If the plan is under ERISA, you are entitled to 100% of billed charges (See Title 29 CFR 2560-503-1.).
If you are non-par and you are entitled to 100% of billed charges, then your choice is to bill the member for an ERISA plan and if State Law allows, bill the member for a plan under State law. Again, the one thing to remember, if you are not contracted, the claim you sent is the member's claim. The carrier is not obligated to pay you. They are obligated to pay the member. For those claims under State Law, your state law may require the HMO to pay you, for example Florida Statute 641.513 requires the HMO to pay the provider but the issue is how much. FS 641.513 (5a-c) states the carrier will pay the provider (a) the amount of the provider's charges or (b) the usual and customary provider charges in the geographical area where the services were performed or (c) an amount negotiated between the HMO and provider within 6 days of claim submission. The problem with this is, the HMOs have made their own determination of usual and customary and there is now a current lawsuit by a Dr. Merkle regarding how the HMOs reimburse the provider.
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Association News
Medical Billing & Coding Education from the MAB
Continuing Education
Management Advice and Training
Questions Asked More Than Once
Help Wanted - Billing and Coding
Non Billing Talk
The Venting Area (Clean posts please)
Medical Coding and Billing News
Fraud and Abuse
Health Insurance - Provider Contracting
ERISA
Tricare
Workers' Compensation
General Medical Billing Questions
Appeals
Accounts Receivables (A/R)
Refunds
Auto Accident Issues
Medisoft Technical Support
Medical Software Technical Support Questions Other than Medisoft. No Investigation Questions!
General Medical Coding Forum
CPT Coding Questions
HCPCS Coding Questions
ICD-9-CM Coding Questions
Evaluation & Management Coding Questions
Acupuncture Billing and Coding
Ambulance Coding and Billing
Cardiology Coding and Billing
Chiropractic Coding and Billing
Dental Billing and Coding
DME Coding and Billing
Emergency Department Coding and Billing
Family Practice Coding and Billing
Hospital Inpatient and Outpatient Coding
Hospital Billing, Appeals and Collections
Internal Medicine Coding and Billing
Laboratory Coding and Billing
Ophthalmology Coding and Billing
OB-GYN Coding and Billing
Pain Management Coding and Billing
Pediatric Coding and Billing
Podiatry Coding and Billing
Physical Therapy Coding and Billing
Psychiatry Coding and Billing
Radiology Coding and Billing
Surgery Coding and Billing
Neurology Coding and Billing
Urgent Care Coding and Billing
Provider Compliance
Billing Center Compliance
HIPAA
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