1/Forgive the history lesson but here goes. Before 1997, prior authorization was usually required for Pts before they presented to the #emergencydepartment. The CMS 1500 paper claim form has a box for the prior authorization number. The Pts PCP had to provide the prior auth number or the visit would not be reimbursed. Pts were instructed to call an after hours “ask a nurse” line to discuss whether they had prior authorization to present to the ED. Patients were being very negatively impacted by either delaying care and/or waiting to come to the ED when their doctor’s office opened. Congress decided that since ED care had been mandated in the 1986 law known as #EMTALA, that there should be commensurate protections of both the Pt and the clinician under what is now known as the #prudentlayperson standard (PLP). If an otherwise prudent lay person believed that they were having an emergency, then prior authorization was prohibited and the presenting symptoms of the patient were essential to determine coverage and payment. The BBA ‘97 was the first federal PLP statute and the ACA in turn built and expanded those protections. Now virtually all health plan policies are now governed by state or federal PLP. Most importantly, CMS has repeatedly stated that the “final diagnosis” cannot be used to determine “coverage or payment” under PLP. Despite clear legal federal and state standards to the contrary, major health plans like @UHC @Centene @AnthemBCBS have engaged in systemic denials of ED claims using generative AI/bots and policies that assess the claim as “non-emergent” based on the final diagnosis. @ACEPNation @EDPMA have 25+ years of advocacy that shows a record of repeated call outs of the health plans for violating PLP. UHC recently also settled a major lawsuit by the US Dept. of Labor claiming its ERISA plan subsidiary, UMR, violated federal PLP for multiple years. Anthem has also settled federal litigation over these issues. Finally, several years ago the Virginia ACEP chapter successfully sued the state and CMS over VA Medicaid’s final diagnosis list with a reported and very favorable US federal court decision which was not appealed by either the state or CMS. This study now confirms (again) how final diagnosis lists are fatally flawed and supports the key principles of PLP. Among discharge diagnosis defined as “very emergent”, e.g. stroke and MI, the initial reasons given for the ED visit for these conditions was classified as emergent less than 50% of the time.

This is an outrage —MA plans w/ an +5% payment bump in ‘25 while the physicians continue to be down -2.83% on Medicare.

In a landmark study analyzing over 50M emergency dept. professional claims over a 4 yr period, @RANDCorporation study shows that the ED safety net that we all rely on has frayed to the point of breaking. In network reimbursements declined nearly 11% & out of network declined nearly -48%, during the 4 yr period which spans both pre-#NoSurprisesAct and post. Uncompensated care defined as bad debt & financial assistance climbed to nearly $47B. Viability of hospital-based emergency care in US faces peril, report suggests medicalxpress.com/news/2025-… via @medical_xpress @ACEPNation @RadiologyACR @AmerMedicalAssn @ahahospitals @ASALifeline @DGlaucomflecken @EDPMA @mcuban @mass_marion @MarilynHeineMD