Can I Go to Any Emergency Room? What is the Prudent Layperson Standard?

any emergency room

Do you know your rights when it comes to your health insurance coverage for emergency visits? Don’t worry, you’re not alone. The average person may not know their rights. But with your money and health at stake, it’s time to be informed. If you’re one of the billions of patients who want the freedom to choose any emergency room, it’s important to know your rights more than ever. Why? So you know exactly what coverage you’re entitled to, and you can feel confident getting treated at whichever emergency facility you choose.

The most important takeaway is that no matter which emergency room you choose (hospital or standalone), your health insurance cannot deny your claim nor charge you out-of-network rates. Through the prudent layperson standard patients can go to any emergency room in an emergency and not worry about pre-authorization or paying high out-of-network rates.

What is the Prudent Layperson Standard?

The prudent layperson standard is a generally accepted principle that protects consumers from high medical costs that arise from emergency situations. Under the prudent layperson standard, emergency rooms should only charge patients in-network rates, no matter which emergency room it is. This standard must remain in federal law and in any healthcare legislation that seeks to replace the Affordable Care Act.

*Medicaid Fee-for Service is the only insured segment not currently covered by this standard.

Why Should I Care About the Prudent Layperson Standard?

When you know your health insurance rights:

  • You won’t ever have to question which emergency facilities to use. The prudent layperson standard protects your rights as a patient and gives you the peace of mind to choose any emergency room you want.
  • You can dispute a denied claim or any unfair costs. For years, health insurance companies denied claims based on final diagnoses instead of symptoms. For example, if you went to an ER for shortness of breath, and it turned out to be a panic attack, some insurance companies wouldn’t pay because it was not a medical emergency after all. The prudent lay person standard protects you from this. It’s also important to know that insurance companies and employers are now trying to shift more costs onto patients and medical providers.
  • You can fight against undue costs and practices.

What Else Can You Do to Protect Your Rights for Emergency Care?

  • Learn more about your rights by visiting Share your story about any emergency visits that were denied.
  • Make sure you find out what your emergency care coverage health insurance policy covers and demand fair and reasonable coverage for emergency care.
  • Report any violations of the prudent layperson standard to your state Department of Insurance.
  • Talk with your state and federal legislators to ensure the prudent layperson standard will not be violated

What is the difference between hospital ERs, standalone ERs, and urgent care clinics? Read about them here. You can also call your local Hospitality Health ER for questions concerning insurance coverage for your ER visit .