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Life Health > Health Insurance > Life Insurance Strategies

Evergreen State Imposes ER Benefits Penalty

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Washington state regulators have issued $65,000 in fines in connection with allegations that a health carrier violated the state’s prudent layperson rule for coverage of emergency room claims.

State officials are accusing Kaiser Foundation Health Plan of the Northwest, Portland, Ore., an affiliate of Kaiser Permanente, Oakland, Calif., of improperly denying insurance claims from 229 policyholders who sought medical care at an emergency room during 2003 and 2004.

Kaiser denied the claims after a physician reviewer made a determination that a medical necessity for emergency care did not exist in those cases, according to Washington officials.

In Washington, state law “requires emergency services to be covered if a prudent layperson, acting reasonably, believes that an emergency medical condition exists, regardless of whether a physician agrees,” officials say.

Kaiser has signed a consent order agreeing to the findings and the fine.

Kaiser has issued a statement noting that it delivers care to more than 130,000 residents of Southwest Washington.

Since Washington regulators questioned Kaiser’s screening of emergency room coverage claims, “we have reviewed and modified, as appropriate, our relevant business practices to ensure past and present compliance with applicable law,” Gail Mathabane, a Kaiser Permanente representative, says in the statement. “We chose not to contest these fines in order to move forward and return our full attention to meeting the health care needs of our members in Washington.”


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