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Ohio sponsor seeks to bar insurer 'downcoding,' strengthen prudent-layperson rule
Summary
Sen. Manchester testified on SB165 to clarify and strengthen Ohio's prudent-layperson emergency-care standard and to ban insurers from retroactively 'downcoding' emergency claims based solely on diagnosis codes, appointment length or procedure codes, citing hospital surveys and provider losses.
Senator Manchester (sponsor) told the Senate Financial Institutions, Insurance and Technology Committee that Senate Bill 165 would strengthen Ohio’s prudent-layperson standard and ban insurers from denying emergency coverage or reducing payments based solely on diagnosis codes, appointment duration, procedure codes or automated "downcoding" practices. She said the bill would require insurers to thoroughly review each claim before issuing a coverage determination and would prohibit plan practices that retroactively recategorize emergency visits as nonemergent.
The sponsor argued the…
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