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Practical application of the prudent layperson standard
CORRESPONDENCE
lence of pulmonary embolism. We recently found that the pretest probability of pulmonary embolism was 17% (95% confidence interval, 11% to 16%)in a US rnulticenter ED study of pulmonary embolism, 4 a prevalence similarto the 95% confidence interval ofthe 17% pretest probability reported in a multicenter study of outpatients conducted in Canada by Ginsberg et al. 5Therefore, it would be important to know the prevalence of pulmonary embolism among nonenrolled ED patients who underwent ventilation-perfusion scintigraphy during their observation period at the authors' institution. This information would help the readerto determine whether selection or spectrum bias existed in the study by Farrell et al.
Jeffrey A. Kline, MD Department of Emergency Medicine Carolinas Medical Center Charlotte, NC 47/8/114462 do/.10.1067/mem.2001.114462 1. Farrell S, Hayes T, Shaw M. A negative simpliRED Ddimer assay result does not exclude the diagnosis of deep vein thrombosis or pulmonary embolus in emergency department patients. Ann Emerg Med. 2000;35:121-125. 2. Kline JA, Johns KL, Colucciello SA, et aI. New diagnostic tests for pulmonary embolism. Ann Emerg Med. 2000;35:168-180. 3. Reber G, de Moerloose P, Coquoz C, et al. Comparison of two rapid D-dimer assays for the exclusion of venous thromboembolism. Blood Coagul Fibrinolysis. 1998;9:387-388. 4. Kline JA, Israel EG, Michelson EA, et al. Diagnostic accuracy of a bedside D-dimer assay and alveolar deadspace measurement for rapid exclusion of pulmonary embolism: a multicenter study. JAMA. 2001;285:761-768. 5. GinsbergJS, Wells PS, Kearon C, et al. Sensitivity and specificity o.f a rapid whole-blood assay for D-dimer in the diagnosis of pulmonary embolism. Ann Intern Med. 1998; 129:1006-1021.
The authors did not wish to reply.
Practical Application of the Prudent Layperson Standard To the Editor. I applaud the efforts of Shesser et al ~(article #109167) to discredit the use ofthe final ED diagnosis as a determinant of managed care policy claims coverage for EDvisits. However, their use of presenting symptoms as an alternative for identifying visits that meet the
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prudent layperson standard has the unfortunate effect of promoting a claims payment methodology that ignores the Emergency Medical Treatment and Active Labor Act (EMTALA) mandate for medical screening examinations and stabilizing care. This mandate applies to all patients who present to the ED, regardless of how minor the presenting symptoms might seem. This screening includes an appropriate history, a physical examination, and the diagnostic studies needed to determine whether an emergency medical condition exists. Identifying the presenting symptoms is only one step (and not always the first)in this process. Managed care plans often expect EDs to make this determination solely on the basis of nursing triage and presenting symptoms, which are never sufficient to meet the EMTALA mandate. This dilemma is particularly difficult for emergency physicians when the managed care plan is a Medicaid plan; in such plans, balance billing ofthe patientwhen the plan denies coverage is often either fruitless or, as it is in California, illegal. Perhaps in recognition ofthis dilemma, in 1995, the California Department of Health Services published a policythat requires Medicaid Managed Care Plans in California to pay providers for medical screening examinations and stabilizing care every time a patient presents to the ED. The Department of Health Services further indicated that because a medical screening examination can be simple or complex, depending on the nature of the problem, the medical history, examination findings, and subsequent diagnostic test results, there could be no such thing as a standard medical screening examination fee. Unfortunately, California Medicaid Managed Care Plans continue to deny and inappropriately down-code emergency physician claims because the Department of Health Services has failed to enforce its own policy. Furthermore, emergency physicians are caught between managed care's narrow definition of necessary stabilizing care and the courts' broad interpretation of this EMTALA mandate. If meningitis develops in only 1 in 10,000 managed care patients who present with minor dermatitis or earache and are screened and discharged from the EDwithout an examination or treatment, within a year or two nearly every ED in the country would potentially face sanc-
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tions for violating EMTALA. What is missing from the prudent layperson standard is consistency with the EMTALA mandate, and, at the very least, Medicaid Managed Care Plans should be required to pay for every medical screening examination, regardless of the presenting symptoms.
R. Myles Riner, MD 47/8/114463 doi:10.1067/mern.2001.114463 1. Shesser R, Holtermann K Smith J, et al. Results of provider self-adjudication using the prudent layperson standard compared with the managed care organization's emergency department claim review process. Ann Emerg Med. 2000;36:212-218.
To the Editor. The article by Dr. Shesser et al 1and the accompanying editorial by Dr. Williams 2 (articl e #109212) relating to the practical appl ication of the prudent layperson standard for the adjudication of ED claims payments demonstrate the inherent inconsistencies associated with retrospective determinations of this type. The findings published in Annalsare very consistent with our observations, and, for this reason, more than 10 years ago, we developed a system to provide prospective or concurrent review for such situations. The Kaiser Permanente Medical Care Program in California has now had active involvement in about 500,000 nonplan EDvisits through its Emergency Prospective Review Program (EPRP).There have been exceedingly few differences of opinion between Kaiser Permanente emergency physicians and nonplan emergency physicians relating to the application of a prudent layperson standard at the time of the actual EDvisit. However, a 24-hour call center staffed by dedicated Kaiser Permanente emergency physicians is required to achieve this level of consistency, as well as very sophisticated computer links that transfer the content of this emergency physician to emergency physician communication to the claims payment systems. The advantages of concurrent or prospective review in determining prudent layperson standards are much broader than the financial benefit to the nonplan facility and the managed care organization (MCO)member. We are confident that we are also contributing to the best opportunity for a good clinical
OF EMERGENCY MEDICINE 37"5 MAY 2001
lence of pulmonary embolism. We recently found that the pretest probability of pulmonary embolism was 17% (95% confidence interval, 11% to 16%)in a US rnulticenter ED study of pulmonary embolism, 4 a prevalence similarto the 95% confidence interval ofthe 17% pretest probability reported in a multicenter study of outpatients conducted in Canada by Ginsberg et al. 5Therefore, it would be important to know the prevalence of pulmonary embolism among nonenrolled ED patients who underwent ventilation-perfusion scintigraphy during their observation period at the authors' institution. This information would help the readerto determine whether selection or spectrum bias existed in the study by Farrell et al.
Jeffrey A. Kline, MD Department of Emergency Medicine Carolinas Medical Center Charlotte, NC 47/8/114462 do/.10.1067/mem.2001.114462 1. Farrell S, Hayes T, Shaw M. A negative simpliRED Ddimer assay result does not exclude the diagnosis of deep vein thrombosis or pulmonary embolus in emergency department patients. Ann Emerg Med. 2000;35:121-125. 2. Kline JA, Johns KL, Colucciello SA, et aI. New diagnostic tests for pulmonary embolism. Ann Emerg Med. 2000;35:168-180. 3. Reber G, de Moerloose P, Coquoz C, et al. Comparison of two rapid D-dimer assays for the exclusion of venous thromboembolism. Blood Coagul Fibrinolysis. 1998;9:387-388. 4. Kline JA, Israel EG, Michelson EA, et al. Diagnostic accuracy of a bedside D-dimer assay and alveolar deadspace measurement for rapid exclusion of pulmonary embolism: a multicenter study. JAMA. 2001;285:761-768. 5. GinsbergJS, Wells PS, Kearon C, et al. Sensitivity and specificity o.f a rapid whole-blood assay for D-dimer in the diagnosis of pulmonary embolism. Ann Intern Med. 1998; 129:1006-1021.
The authors did not wish to reply.
Practical Application of the Prudent Layperson Standard To the Editor. I applaud the efforts of Shesser et al ~(article #109167) to discredit the use ofthe final ED diagnosis as a determinant of managed care policy claims coverage for EDvisits. However, their use of presenting symptoms as an alternative for identifying visits that meet the
5
5
0
A
N
prudent layperson standard has the unfortunate effect of promoting a claims payment methodology that ignores the Emergency Medical Treatment and Active Labor Act (EMTALA) mandate for medical screening examinations and stabilizing care. This mandate applies to all patients who present to the ED, regardless of how minor the presenting symptoms might seem. This screening includes an appropriate history, a physical examination, and the diagnostic studies needed to determine whether an emergency medical condition exists. Identifying the presenting symptoms is only one step (and not always the first)in this process. Managed care plans often expect EDs to make this determination solely on the basis of nursing triage and presenting symptoms, which are never sufficient to meet the EMTALA mandate. This dilemma is particularly difficult for emergency physicians when the managed care plan is a Medicaid plan; in such plans, balance billing ofthe patientwhen the plan denies coverage is often either fruitless or, as it is in California, illegal. Perhaps in recognition ofthis dilemma, in 1995, the California Department of Health Services published a policythat requires Medicaid Managed Care Plans in California to pay providers for medical screening examinations and stabilizing care every time a patient presents to the ED. The Department of Health Services further indicated that because a medical screening examination can be simple or complex, depending on the nature of the problem, the medical history, examination findings, and subsequent diagnostic test results, there could be no such thing as a standard medical screening examination fee. Unfortunately, California Medicaid Managed Care Plans continue to deny and inappropriately down-code emergency physician claims because the Department of Health Services has failed to enforce its own policy. Furthermore, emergency physicians are caught between managed care's narrow definition of necessary stabilizing care and the courts' broad interpretation of this EMTALA mandate. If meningitis develops in only 1 in 10,000 managed care patients who present with minor dermatitis or earache and are screened and discharged from the EDwithout an examination or treatment, within a year or two nearly every ED in the country would potentially face sanc-
N
A
L
S
tions for violating EMTALA. What is missing from the prudent layperson standard is consistency with the EMTALA mandate, and, at the very least, Medicaid Managed Care Plans should be required to pay for every medical screening examination, regardless of the presenting symptoms.
R. Myles Riner, MD 47/8/114463 doi:10.1067/mern.2001.114463 1. Shesser R, Holtermann K Smith J, et al. Results of provider self-adjudication using the prudent layperson standard compared with the managed care organization's emergency department claim review process. Ann Emerg Med. 2000;36:212-218.
To the Editor. The article by Dr. Shesser et al 1and the accompanying editorial by Dr. Williams 2 (articl e #109212) relating to the practical appl ication of the prudent layperson standard for the adjudication of ED claims payments demonstrate the inherent inconsistencies associated with retrospective determinations of this type. The findings published in Annalsare very consistent with our observations, and, for this reason, more than 10 years ago, we developed a system to provide prospective or concurrent review for such situations. The Kaiser Permanente Medical Care Program in California has now had active involvement in about 500,000 nonplan EDvisits through its Emergency Prospective Review Program (EPRP).There have been exceedingly few differences of opinion between Kaiser Permanente emergency physicians and nonplan emergency physicians relating to the application of a prudent layperson standard at the time of the actual EDvisit. However, a 24-hour call center staffed by dedicated Kaiser Permanente emergency physicians is required to achieve this level of consistency, as well as very sophisticated computer links that transfer the content of this emergency physician to emergency physician communication to the claims payment systems. The advantages of concurrent or prospective review in determining prudent layperson standards are much broader than the financial benefit to the nonplan facility and the managed care organization (MCO)member. We are confident that we are also contributing to the best opportunity for a good clinical
OF EMERGENCY MEDICINE 37"5 MAY 2001