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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