The HMO debate: Who decides emergency care?

Delores Leatherberry waits in her husband Maurice's room as a hospital worker attends to him. The couple had no prior approval from their HMO before taking Maurice to the emergency room  Emergency-room care proposals: Democrats: Require health plans to pay for reasonable care even if the hospital is outside the network. That includes any care needed to stabilize and treat the patient. Republicans: Require payment only for stabilization. Only applies to federally regulated plans

July 14, 1999
Web posted at: 4:10 p.m. EDT (2010 GMT)

In this story: Patient vs. payer HMOs challenged on compliance Study: HMO instructions confusing RELATED STORIES, SITES

CHICAGO (CNN) -- Delores and Maurice Leatherberry have had their share of run-ins with their HMO, the latest coming this week when Maurice, 28, suffered a seizure. His wife took him to a hospital without receiving prior approval from their insurance company.

"I did not speak to them since I've been here," Delores told CNN. "I don't even know if (the hospital has) contacted them. I don't even know if they're going to pay for this."

It happened before, when her son needed emergency room care. "They sent me a bill saying I was not given approval, so I owe them," she said.

Having heard similar complaints about coverage under health maintenance organizations, Congress is working on a remedy. Democrats and Republicans even agree on what to call it -- a patients' bill of rights. But that's where the similarity ends.

Patient vs. payer

At issue: Who decides when an emergency room visit is medically necessary -- the patient or an insurance company?

Congressional members agree that Americans need a patients' bill of rights, but they disagree on the terms

Many physicians believe insured Americans are increasingly becoming victims of economic triage.

Patients may receive the urgent care they need, says Dr. John Graneto, an emergency room physician, only to go through an even more traumatic experience afterward -- fighting with their insurance company.

In the patients' bill of rights debate, Democrats want what they call a "prudent layperson" standard -- one that allows the patient, not the payer, to decide when an emergency exists.

The patient, in this case, is the "prudent layperson."

The proposal calls for the elimination of prior approvals and would require HMOs to pay for any necessary follow-up treatment.

HMOs challenged on compliance

Already in effect for Medicare/Medicaid recipients and federal employees, the "prudent layperson" standard is also the law in 28 states.

Dolores Leatherberry: 'I don't even know if they are going to pay for this'

But compliance has been spotty: