But only Florida's prudent layperson law explicitly gives physicians such powers, according to Hufstetler. Last summer, the Florida insurance commissioner forced insurers to comply with the law. Hufstetler said payments have improved dramatically since then. In other states, insurance interests want to preserve their right to make payment determinations in a payment area that has long been identified with high levels of unnecessary charges. The industry estimates that more than half of ED visits are unnecessary.
Emergency physicians disagree.
They insist that almost all nonemergency visits are necessary and, in fact, qualify for the prudent layperson definition, which includes patients with severe pain and broken bones. A few state regulators are beginning to agree with that assessment and have ordered plans to pay all nonemergency claims without reviews. And Ohio Medicaid officials have pressured several Medicaid HMOs, including the largest in the area, Dayton Area Health Plan, to approve all nonemergency claims. Dayton Area Health Plan has seen only a small rise in costs because it negotiated lower rates for nonemergency claims with contracted hospitals and manages ED use by steering members to other providers, said President Pam Morris. Plans would also pay all prudent layperson claims under a bill drafted by the Maryland chapter of ACEP, which is expected to be introduced soon.