WASHINGTON – A 23-year-old Baltimore woman who was five months pregnant was involved in a car accident last year and started suffering abdominal pain. She went to the emergency room at Harbor Hospital Center out of fear of losing her baby.
But her health insurer, Prudential, decided her condition had not warranted an emergency room visit and initially declined to pay her bill.
The Baltimore hospital had to appeal the decision twice before Prudential paid, said Dr. Linda DeFeo, director of emergency medicine.
Horror stories like this one prompted Rep. Ben Cardin to sponsor a bill that would require all health insurers – including Medicare and Medicaid – to pay for emergency room care based upon a patient’s symptoms, rather than the final diagnosis.
“We’ve all heard horror stories in which someone has been denied payment for an emergency room visit because their chest pains didn’t turn out to be an heart attack,” said Cardin, a Baltimore Democrat, in a written statement. “This bill would end that by standardizing the `prudent layperson’ definition of an emergency” for reimbursement purposes.
It would put an end to “after-the-fact” denials of coverage, he said.
The bill would allow patients to seek treatment from the nearest hospital without getting prior approval from an insurer.
Sen. Barbara Mikulski, D-Baltimore, cosponsored a companion bill introduced by Sen. Bob Graham, D-Fla.
Maryland has similar legislation in place but health maintenance organizations routinely ignore the law, DeFeo said.
Dr. Georges Benjamin, a deputy secretary for the Maryland Department of Mental Health and Hygiene, said the federal statute is needed to force insurers to pay.
Between July 1 and Sept. 30 last year, 28 percent of the emergency room bills sent by Harbor Hospital Center to health maintenance organizations were denied for one reason or another, some of them invalid, DeFeo said. When claims are turned down, the hospital has to go through a contentious appeals process, she said.
Another problem is that employers with self-funded insurance programs are not covered by state law. Jeannette Duerr, a spokeswoman for the Maryland Department of Health and Mental Hygiene, said 844,000 Marylanders have this insurance.
Cardin’s bill has been criticized by the American Association of Health Plans, a trade group representing 1,000 health plans insuring 140 million people.
The group does not want the federal government involved in the delivery of medical services, said spokesman Donald White.
Furthermore, White said, the bill is too vague. “What is a `prudent layperson?’ ” he asked.
But the largest health maintenance organization, Kaiser Permanente, endorsed the bill for the first time this year. It supports the measure because it will standardize emergency care regulations, said associate medical director Dr. John T. Pappas.
Kaiser Permanente insures 7.4 million people in 17 states and the District of Columbia.
The American College of Emergency Physicians, the American Medical Association and the American Hospital Association are among others that have also endorsed the bill.
Cardin’s bill has five Republican cosponsors and 18 Democratic cosponsors. No hearings have yet been scheduled. Cardin introduced a similar bill in 1995. It was referred to two House subcommittees, which never voted on it. -30-