The FAQ & Timeline will help show how the Prudent Layperson Standard (PLP) is still protecting patients over 30 years later. With the latest developments concerning CMS’ approval of Virginia Medicaid’s Emergency Department downcoding policy, it is important to understand where it all began.
The PLP emerged in the 1990s when a Maryland-based emergency physician while pursuing his law degree, learned how it protected consumers. He took the concept to the Maryland legislature in 1993 and applied it to emergency care to protect patients presenting with severe symptoms in the emergency department (ED). Now, anyone with commercial or government insurance is covered under the PLP.
The PLP ensures that enrollees have unfettered access to health care for emergency medical conditions and that providers of emergency services receive payment for those claims meeting that definition without having to navigate through unreasonable administrative burdens. This standard iterates that the final determination of coverage and payment must be made considering the presenting symptoms rather than the final diagnosis.
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