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.