UnitedHealthcare Retroactive Denial of Emergency Care and the Prudent Layperson Standard

Vicki Norton MD FAAEM, AAEM Board of Directors
Saba Rizvi, MD FAAEM

AAEM recognizes UnitedHealthcare’s deferment of their dangerous and ill-advised policy to limit patients seeking emergency care.

Patients who fear they are having a true emergency should not be deterred from going to the emergency department. They should not be concerned about their insurance later denying coverage for their emergency department visit. Patients are protected from this under what is known as the Prudent Layperson Standard. The prudent layperson standard is not an issue contingent on the pandemic response but has served as sound policy in encouraging patients to seek emergency medical care at all times in our nation.

In 1997, Congress enacted Prudent Layperson Standard laws for Medicare and Medicaid managed care plans, which states: “The term ‘emergency medical condition’ means a medical condition manifesting itself by acute symptoms of sufficient severity (including severe pain) such that a prudent layperson, who possesses an average knowledge of health and medicine, could reasonably expect the absence of immediate medical attention to result in: placing the health of the individual (or, in the case of a pregnant woman, the health of the woman or her unborn child) in serious jeopardy, serious impairment to bodily functions, or severe dysfunction of any bodily organ or part, [or] serious disfigurement.”

All federal employees became covered by the Prudent Layperson Standard in 1999. The Affordable Care Act in 2010 expanded the Prudent Layperson Standard even further to individual and small group health plans and to self-funded employer plans. AAEM advocates for a strong national solution to end the retroactive denial of emergency department claims by private insurance.

For more information regarding AAEM’s stance on PLS, please see our past position statements and news releases:

https://www.aaem.org/UserFiles/BalanceBillingPaper.pdf https://www.aaem.org/UserFiles/file/CS18_JulyAug_v5_GovNatl.pdf