What is Prudent Lay?

What is Prudent Lay?
Prudent Lay Person is an individual defined as having a limited understanding of medicine and health, thus they are deemed a “lay person” – this is where the Lay part of Prudent Lay comes from.
This occupation was created in order to ensure Emergency Room (Emergency Department) claims to providers were being paid based not on the medical condition or the diagnosis of the physician but on the perceived necessity of an “average” person with limited medical knowledge. It is not based on the final condition of the member’s visit – rather it is based on the presenting symptoms and how critical they are perceived to the member.

This website is to educate and inform physicians, nurses, insurance companies and the general public regarding the Prudent Lay Person Standard and the Prudent Lay Person profession.

Where do Prudent Lay people work?
Primarily a prudent lay person is employed in health insurance companies. Since the title is unusual, many people are often curious about its origin.

Welcome to The Complete Reference to The Prudent Lay Profession – PrudentLay
Cited from Pugetsound.va.gov:

The Prudent Layperson Fact Sheet:
“In 1986, Congress enacted the Emergency Medical Treatment and Labor Act (EMTALA) governing the provision and payment of emergency medical services in Medicare participating hospitals. In 1994 a revision to the act added the “prudent layperson” definition as a standard for evaluating whether a patient has an emergency condition. The Balanced Budget Act of 1997 established the “prudent layperson” standard for Medicaid effective October 1997 and the same standard became effective for Medicare in May 1998. The Department of Veterans Affairs adopted the standard in November 1999 when the Veterans Millennium Health Care and Benefits Act prescribed the “prudent layperson” standard for evaluating emergency care as one of the criteria for authorization and payment of emergency treatment for nonservice-connected conditions. The prudent layperson definition of an emergency medical condition commonly in practice is any medical or behavioral condition of recent onset and severity, including but not limited to severe pain, that would lead 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 placing the patient’s health in serious jeopardy, cause serious impairment to bodily functions, serious dysfunction of any bodily organ or part, or in the case of a behavioral condition placing the health of such person or others in serious jeopardy. This prudent layperson definition of emergency medical condition focuses on the patient’s presenting symptoms rather than the final diagnosis when determining whether to pay emergency medical claims. Note: Under the prudent layperson standard payment for emergency care is made for the initial evaluation and examination based upon the nature of the patient’s presenting complaint. Payment may be made for additional medical services until the condition is no longer clinically determined to be emergent in nature and the patient is stable for transfer to VA or discharge.”
If you have any additional questions about this unusual profession, please contact us.

On our website you may be able to locate a job in this profession:

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What is the Prudent Man Rule?

This legal definition is for disambiguation purposes only, and is not related to the Prudent Layperson Standard in health care. However, as a courtesy, we provide this term here as it contains a common search phrase that people seek:

“Prudent Man Rule is an investment standard. It directs trustees “to observe how men of prudence, discretion and intelligence manage their own affairs, not in regard to speculation, but in regard to the permanent disposition of their funds, considering the probable income, as well as the probable safety of the capital to be invested”. [Harvard College v. Armory 9 Pick (26 Mass) 446, 461 (1830).]

In some states, the law requires that a fiduciary, such as a trustee, may invest the fund’s money only in a list of securities designated by the state,the legal list. In other states, the trustee may invest in a security if it is one that would be bought by a prudent person of discretion and intelligence, who is seeking a reasonable income and preservation of capital.”

SOURCE: Legal Definitions of Prudent Man, Prudent Man Rule

Under Obamacare Er Costs Actually Increased

Based on 2011 data by the Health Cost Institute (PDF), the average cost of er visits increased by 5%, to about $1,381 per emergency room visit.

That is about a month of rent for some Americans. It remains above $1,000 per visit (average) nationally. This is much more than an average Primary Care visit to the doctor.

However, in the Obamacare health care paradigm, the frequency of er visits is increasing.

Why? PCP’s may be turning down patients because the Obamacare health plans don’t give a high enough reimbursement to physicians and clinics.

ER Costs
The above table by CareFirst.com compares Urgent Care costs versus Er costs, based on presenting symptoms.

A 2015-typical emergency room visit for a cough shouldn’t cost $1000, but the resources needed to run an emergency room department often require these charges: ER’s are equipped with modern technology, 24/7 nurse and physician staff that is specially trained for acute emergent situations, not to mention security staff for protection of patients, visitors and staff.

But there are even more startling developments regarding er costs that would shock most people:

There is a huge variation in the cost of each er visit: “Bills sent out for sprained ankles ranged from $4 to $24,110,” according to a report by the Washington Post.