Many patients seek care in the emergency department only to have their insurance coverage denied because their insurance carrier decides that the emergency visit was not necessary. In some cases the reason was the final diagnosis was considered and emergency condition, although the reason for the visit may well be justified. The classic example of this is a patient who thinks they are having a heart attack, but the doctors determines it was only heartburn.

The Federal Government has provided protection for all Medicare and Medicaid beneficiaries and many states and individual insurers have also adopted the "Prudent Layperson" definition for determining the need for care.

Federal legislation defined by congress for Medicare and Medicaid beneficiaries defines a covered "emergency medical condition" as "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—(i) placing the health of the individual (or, with respect to a pregnant woman, the health of the woman or her unborn child) in serious jeopardy, (ii) serious impairment of bodily functions, or (iii) serious dysfunction of any bodily organ or part."

Although many states have already passed similar legislation, New Jersey still has not adopted a "Prudent Layperson" law. However many insurers do follow the national guidelines and use a prudent layperson standard (check your policy). This protection is guaranteed to New Jersey patients who are Medicare and Medicaid beneficiaries under the federal law. It is very important for New Jersey to pass prudent layperson legislation to protect the public. Physicians groups, including the American Medical Association (AMA) and the American College of Emergency Physicians (ACEP), support prudent layperson legislation. They view a patient’s ability to seek and receive coverage for emergency medical services as an important right. Call or write your representatives to voice your opinion.

If you have payment for a visit denied, Jersey Emergency Specialists will generally automatically file an appeal on your behalf if the documentation from the visit supports a possibility of an emergency medical condition that could have needed evaluation. You should also call your insurer to complain if you feel your visit was denied inappropriately. A representative of Jersey Emergency Specialist can assist you with this and supply information including a doctor's letter if appropriate.