Analysis of insurance payment denials using the prudent layperson standard

To review a sample of emergency department payment denials characterized as "not a medical emergency" and to determine medical necessity for each visit using an arbitrary "prudent layperson" standard.

This study was conducted at a university hospital and was an analysis of a convenience sample of ED payment denials classified as "not a medical emergency" by 2 managed care providers. Each corresponding visit was analyzed if the bill was still outstanding in September 1998. ED records were analyzed for chief complaint and risk factors for morbidity. Any minor disorder lasting 1 day or more and with normal vital signs recorded was considered to not meet the prudent layperson standard of an emergency. Visits for minor trauma that occurred the same day that also required radiographs or suturing were considered emergencies.

Two hundred ED visits were retrospectively reviewed. Payer 1 denied 44 visits, of which 38 (86%) met the prudent layperson standard; payer 2 denied 156 visits, of which 113 (62%) met the standard (P >.05).

A large proportion of ED visits for which payment is denied as "not a medical emergency" may meet the prudent layperson definition of an emergency.