Ems System Performance-Based Funding And Reimbursement Model - Finance Committee Draft Advisory Page 12
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34Finance Committee DRAFT Advisory
EMS System Performance-based Funding and Reimbursement Model
Prudent Layperson Standard Establishes Medical Necessity for Response and Payment Purposes.
Historically, the standard for determining the need for both an emergency medical response and
an emergency department visit is the “prudent layperson” definition of emergency. The standard
defines an emergency as:
Any medical condition of recent onset and severity, including but not limited to severe
pain, that would lead to a prudent layperson, possessing an average knowledge of
medicine and health, to believe that his or her condition, sickness, or injury is of such
a nature that failure to obtain immediate medical care could result in: 1) placing the
patient’s health in serious jeopardy, 2) serious impairment to bodily function, or 3)
serious dysfunction of any bodily organ or part (ACEP, 2002 and NAEMSP, 2011).
This standard is applicable to bystanders, patients and EMS providers as none of these entities
are trained to diagnose. The need for emergency medical response is based upon the patients’
condition at the time of request (i.e., the 9-1-1 call). The 9-1-1 dispatch center and/or medical
communications center makes a determination to dispatch an EMS response unit. The arriving
EMS crew (first response unit or ambulance transport unit) provides an initial assessment of the
patient, provides medical treatments based upon physician-approved or standing protocols, and
transports the patient to the emergency department. As the NAEMSP Resource Document
describes, it is important that EMS providers appropriately document each patient contact with
an assessment; in addition, it is important to document the patient’s capacity to understand the
nature of the illness (NAEMSP, 2011).
Medicare has established ambulance fee schedule regulations that recognize the prudent
layperson standard for the purpose of determining medical necessity for payment of emergency
medical responses. Retrospective medical necessity denials by insurers are becoming more
frequent and this trend is extremely problematic. Inappropriate retrospective payment delays,
down-coding or denials generally fail to recognize the prudent layperson standard, the limitations
in current EMS scope of practice and the cost incurred to respond to the patient and to perform
the initial patient assessment.
Assuring Access to Care. Recently, CMS has proposed national guidelines and state Medicaid
programs have begun to implement a new Access to Care Standard for the purpose of
determining Medicaid payment levels. In establishing Medicaid reimbursement amounts, the
federal regulations regarding access to care (Section 1902(a)(30)(A) of the Social Security Act)
requires States to:
. . . assure that payments are consistent with efficiency, economy, and quality of care
and are sufficient to enlist enough providers so that care and services are available
under the plan at least to the extent that such care and services are available to the
general population in the geographic area.
It is essential that any access to care analysis by State Medicaid programs address emergency-
specific mandates to provide care regardless of reimbursement amounts. This should be
accomplished by developing a unique measure for evaluating access to emergency medical
March 29,2012
Draft Advisory
12
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