|June 10, 2019
Governor Signs Bill Enacting "Prudent Layperson" Standard
Last Friday Governor Janet Mills signed LD 1155 into law. It enacts a "prudent layperson" standard for determining when an insurance carrier may not deny or reduce benefits for a patient presenting to an emergency department on the grounds that the patient's condition turned out not to be an emergency.
The law, now known as Public Law 2019 chapter 238, requires that the determination of the reasonableness of the patient's decision, and thus the coverage for the treatment, must be based on the standard of whether a prudent layperson, not a medical expert, would believe that the situation presented a medical emergency. Emergency services must be covered without prior authorization.
The law further provides that before a carrier determines the absence of an emergency, it must conduct a utilization review performed by a board certified emergency physician licensed in Maine.
A related bill, LD 249 (now PL 2019 c. 171), requires that an appeal of a carrier's adverse health care treatment decision must be conducted by a clinical peer, defined as a physician or other healthcare practitioner licensed in the U.S. and board certified in the same or a similar specialty as typically manages the condition under review and whose compensation for the review does not depend on a history of approvals or denials.Next Article >
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