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Prudent PG-96 - History

Prudent PG-96 - History



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Prudent

(PG-96 : dp. 1,375 (f.); 1. 205'; b. 33'; dr. 14'6"; cpl. 87; s. 16 k.;
a. 2 3", 4 20mm., 2 det., 4 dcp., 1 dcp. (hh.); cl. Action)

Prudent (PG-96), originally projected as HMS Privet (CN314), wa.s laid down by the Morton Engine and Dry Dock Co. Ltd., Montreal, Que., 14 August 1942, Iaunehed 4 December 1942; sponsored by Mrs. Vineent Godfrey, delivered to the U.S. Navy 14 August 1943; and commissioned 16 August 1943, Lt. A. F. Pittman, U.S.C.G., in command.

Following shakedown off Bermuda, Prudent steamed to New York to begin a series of east enast—Cuba escort runs. Sailing with her first convoy 7 December 1943, she completed her 11th run, at New York, 21 December 1944. During January and into February 1945 she patrolled the sea lanes off the New England coast, then, on 20 February, departed New York on her last escort assignment to Guantanamo Bay. Returning to New York 15 March, she resumed patrol duties and for the remainder of the war in Europe plied the waters off the northeast coast.

Ordered inactivated at the end of the war, Prudent sailed south, 11 June, to Norfolk, thence to Charleston where she decommissioned 11 October 1945. Struck from the Navy List 1 November 1945, she was transferred to the Maritime Commission for disposal 22 September 1947. In 1949 the ship was acquired by the Italian Navy and renamed bilbano. In 1951 she was converted to a hydrographie survey vessel and renamed a fourth time, Staffetta. Since that time, into 1970 she has continued to serve the Italian Navy under that name.


Prudent

wise, sage, sapient, judicious, prudent, sensible, sane mean having or showing sound judgment. wise suggests great understanding of people and of situations and unusual discernment and judgment in dealing with them. wise beyond his tender years sage suggests wide experience, great learning, and wisdom. the sage advice of my father sapient suggests great sagacity and discernment. the sapient musings of an old philosopher judicious stresses a capacity for reaching wise decisions or just conclusions. judicious parents using kindness and discipline in equal measure prudent suggests the exercise of restraint guided by sound practical wisdom and discretion. a prudent decision to wait out the storm sensible applies to action guided and restrained by good sense and rationality. a sensible woman who was not fooled by flattery sane stresses mental soundness, rationality, and levelheadedness. remained sane even in times of crises


EMTALA and Prudent Layperson Standard FAQ

Does Prudent Layperson affect billing and reimbursement?

Is Prudent Layperson applicable to managed care plans?

How does EMTALA impact coding, billing and reimbursement?

What is the Prudent Layperson Standard?

Do all Payers recognize EMTALA and the Prudent Layperson in their payment policies?

How do I assure that the medical necessity for treatment in the emergency department is identified for billing?

Answer

According to CMS, Congress enacted the Emergency Medical Treatment & Labor Act (EMTALA) in 1986 &ldquoto ensure public access to emergency services regardless of ability to pay&rsquo. Section 1867 of the Social Security Act imposes specific obligations on Medicare-participating hospitals that offer emergency services to provide a medical screening examination (MSE) when a request is made for examination or treatment for an emergency medical condition (EMC), including active labor, regardless of an individual's ability to pay. Hospitals are then required to provide stabilizing treatment for patients with EMCs. If a hospital is unable to stabilize a patient within its capability, or if the patient requests, an appropriate transfer should be implemented.&rdquo

Answer

According to CMS, Congress enacted the Emergency Medical Treatment & Labor Act (EMTALA) in 1986 &ldquoto ensure public access to emergency services regardless of ability to pay&rsquo. Section 1867 of the Social Security Act imposes specific obligations on Medicare-participating hospitals that offer emergency services to provide a medical screening examination (MSE) when a request is made for examination or treatment for an emergency medical condition (EMC), including active labor, regardless of an individual's ability to pay. Hospitals are then required to provide stabilizing treatment for patients with EMCs. If a hospital is unable to stabilize a patient within its capability, or if the patient requests, an appropriate transfer should be implemented.&rdquo

How does EMTALA impact coding, billing and reimbursement?

Answer

As outlined above, EMTALA obligates Medicare participating hospitals to provide a medical screening examination when a patient presents to the emergency department for examination or treatment for an emergency medical condition (EMC). Until the medical screening examination is provided, hospitals may not query the patient about insurance or payment. EMTALA is, basically, an unfunded federal mandate with the greatest responsibility placed on the hospitals and emergency physicians who provide this care shouldering the financial burden of providing EMTALA related medical care whether or not payment is made, according to the EMTALA Fact Sheet prepared by ACEP.

Some health insurance plans retrospectively deny claims for emergency departments visits, based on a patient's final diagnosis, rather than the presenting symptoms (e.g., when chest pain turns out not to be a heart attack). ACEP advocates for a national prudent layperson emergency care standard that provides coverage based on a patient's presenting symptoms, rather than the final diagnosis. In addition, health insurers should cover EMTALA-related services up to the point an emergency medical condition can be ruled out or resolved.

Answer

As outlined above, EMTALA obligates Medicare participating hospitals to provide a medical screening examination when a patient presents to the emergency department for examination or treatment for an emergency medical condition (EMC). Until the medical screening examination is provided, hospitals may not query the patient about insurance or payment. EMTALA is, basically, an unfunded federal mandate with the greatest responsibility placed on the hospitals and emergency physicians who provide this care shouldering the financial burden of providing EMTALA related medical care whether or not payment is made, according to the EMTALA Fact Sheet prepared by ACEP.

Some health insurance plans retrospectively deny claims for emergency departments visits, based on a patient's final diagnosis, rather than the presenting symptoms (e.g., when chest pain turns out not to be a heart attack). ACEP advocates for a national prudent layperson emergency care standard that provides coverage based on a patient's presenting symptoms, rather than the final diagnosis. In addition, health insurers should cover EMTALA-related services up to the point an emergency medical condition can be ruled out or resolved.

Answer

EMTALA applies when an individual "comes to the emergency department." A dedicated emergency department is defined as "licensed by the State . . . as an . . . emergency department&rdquo or &ldquois held out to the public . . . as a place that provides care for emergency medical conditions." This means that hospital-based outpatient clinics are not obligated under EMTALA unless they provide more than one-third of care as unscheduled AND those 1/3 visits are emergency medical conditions as defined by the statute. EMTALA applies to all aspects of emergency care, including specialists, all available tests and procedures, and anything else necessary to determine or stabilize an emergency medical condition. Additionally, a hospital must report any time it has reason to believe it may have received an individual who has been transferred in an unstable condition in violation of EMTALA.

Answer

EMTALA applies when an individual "comes to the emergency department." A dedicated emergency department is defined as "licensed by the State . . . as an . . . emergency department&rdquo or &ldquois held out to the public . . . as a place that provides care for emergency medical conditions." This means that hospital-based outpatient clinics are not obligated under EMTALA unless they provide more than one-third of care as unscheduled AND those 1/3 visits are emergency medical conditions as defined by the statute. EMTALA applies to all aspects of emergency care, including specialists, all available tests and procedures, and anything else necessary to determine or stabilize an emergency medical condition. Additionally, a hospital must report any time it has reason to believe it may have received an individual who has been transferred in an unstable condition in violation of EMTALA.

What is the Prudent Layperson Standard?

Answer

Health insurance companies for years have denied claims based on the final diagnoses instead of the presenting symptoms that initially brought the patient to the emergency department seeking treatment. For example, if a patient presented to the emergency department with chest pain, but it turned out to be gastric reflux or non-cardiac related, the insurance company would deny payment as non-emergent.

The Prudent Layperson language, adopted individually by most States, defines an emergency medical condition as: A medical condition manifesting itself by acute symptoms of sufficient severity (including severe pain) such that a prudent layperson, who possesses an average knowledge of health and medicine, could reasonably expect the absence of immediate medical attention to result in: a) placing the patient&rsquos health in serious jeopardy b) serious impairment to bodily functions or c) serious dysfunction of any bodily organ or part.

According to ACEPs White Paper on Prudent Layperson, &ldquoACEP fought hard for many years at both the national and state levels to secure passage of legislation aimed at protecting emergency patients from retroactive denials of insurance coverage for emergency department visits for conditions that turned out not to be emergencies&rdquo.

In 1997, Congress enacted the Prudent Layperson Standard for Medicare and Medicaid managed care plans. (https://www.ahcmedia.com/articles/48670-congress-adopts-prudent-layperson-standard-for-medicare-medicaid-enrollees.) The prudent layperson standard was extended to all federal employees in 1999. The Affordable Care Act in 2010 also extended the Prudent Layperson Standard even further to individual- and small-group health plans, and to self-funded employer plans.

Answer

Health insurance companies for years have denied claims based on the final diagnoses instead of the presenting symptoms that initially brought the patient to the emergency department seeking treatment. For example, if a patient presented to the emergency department with chest pain, but it turned out to be gastric reflux or non-cardiac related, the insurance company would deny payment as non-emergent.

The Prudent Layperson language, adopted individually by most States, defines an emergency medical condition as: A medical condition manifesting itself by acute symptoms of sufficient severity (including severe pain) such that a prudent layperson, who possesses an average knowledge of health and medicine, could reasonably expect the absence of immediate medical attention to result in: a) placing the patient&rsquos health in serious jeopardy b) serious impairment to bodily functions or c) serious dysfunction of any bodily organ or part.

According to ACEPs White Paper on Prudent Layperson, &ldquoACEP fought hard for many years at both the national and state levels to secure passage of legislation aimed at protecting emergency patients from retroactive denials of insurance coverage for emergency department visits for conditions that turned out not to be emergencies&rdquo.

In 1997, Congress enacted the Prudent Layperson Standard for Medicare and Medicaid managed care plans. (https://www.ahcmedia.com/articles/48670-congress-adopts-prudent-layperson-standard-for-medicare-medicaid-enrollees.) The prudent layperson standard was extended to all federal employees in 1999. The Affordable Care Act in 2010 also extended the Prudent Layperson Standard even further to individual- and small-group health plans, and to self-funded employer plans.

Does Prudent Layperson affect billing and reimbursement?

Answer

According to EMTALA, Medical Screening Examination and/or stabilizing treatment is not to be delayed in order to inquire about payment status. This does not, however, assure that payers will pay for emergency treatment when treatment is for a condition that does not qualify for emergency payment according to their own unique guidelines. For example, some payers use a diagnosis list to determine payment and if the ED visit is performed for a problem not listed, payment may be denied or paid at an allowable rate for a lower level of service, arbitrarily assigned by the payer. Providers always have an opportunity to appeal a payer&rsquos decision and it is advised that emergency providers appeal unfair payment decisions when made they are made. Although EMTALA and Prudent Layperson were not designed as a billing and payment policy per se, they give each patient with an &ldquoaverage knowledge of health and medicine&rdquo the right to seek emergency care for problems they deem as &ldquoserious&rdquo.

Answer

According to EMTALA, Medical Screening Examination and/or stabilizing treatment is not to be delayed in order to inquire about payment status. This does not, however, assure that payers will pay for emergency treatment when treatment is for a condition that does not qualify for emergency payment according to their own unique guidelines. For example, some payers use a diagnosis list to determine payment and if the ED visit is performed for a problem not listed, payment may be denied or paid at an allowable rate for a lower level of service, arbitrarily assigned by the payer. Providers always have an opportunity to appeal a payer&rsquos decision and it is advised that emergency providers appeal unfair payment decisions when made they are made. Although EMTALA and Prudent Layperson were not designed as a billing and payment policy per se, they give each patient with an &ldquoaverage knowledge of health and medicine&rdquo the right to seek emergency care for problems they deem as &ldquoserious&rdquo.

Do all Payers recognize EMTALA and the Prudent Layperson in their payment policies?

Answer

Unfortunately, some payers look at the diagnosis codes assigned to the final diagnosis statement in in the record to determine the medical necessity of the visit rather than consider the symptoms that required the work-up to determine a final diagnosis or rule out a life threatening condition. For example, a patient may come to the ED because of chest pain, receive a full chest pain work up (i.e., an EKG, a chest x-ray with interpretations, labs including cardiac enzymes, and PO or IV medication) and receive a discharge diagnosis of costochondritis. Although the discharge diagnosis is not life threatening or considered very serious, the physician utilized high cognitive resources during the ED visit to determine the final diagnosis. According to Medicare.gov, &ldquomedically necessary&rdquo is defined as &ldquohealth-care services or supplies needed to prevent, diagnose, or treat an illness, injury, condition, disease, or its symptoms and that meet accepted standards of medicine.&rdquo Thus, the service should be considered appropriate and medically necessary.

By contrast, Cigna, a large private payer, defines Medically Necessary" or "Medical Necessity" as &ldquohealth care services that a physician, exercising prudent clinical judgment, would provide to a patient. The service must be:

  1. For the purpose of evaluating, diagnosing, or treating an illness, injury, disease, or its symptoms
  2. In accordance with the generally accepted standards of medical practice
  3. Clinically appropriate, in terms of type, frequency, extent, site, and duration, and considered effective for the patient's illness, injury, or disease
  4. Not primarily for the convenience of the patient, health care provider, or other physicians or health care providers
  5. Not more costly than an alternative service or sequence of services at least as likely to produce equivalent therapeutic or diagnostic results as to the diagnosis or treatment of that patient's illness, injury, or disease.
Answer

Unfortunately, some payers look at the diagnosis codes assigned to the final diagnosis statement in in the record to determine the medical necessity of the visit rather than consider the symptoms that required the work-up to determine a final diagnosis or rule out a life threatening condition. For example, a patient may come to the ED because of chest pain, receive a full chest pain work up (i.e., an EKG, a chest x-ray with interpretations, labs including cardiac enzymes, and PO or IV medication) and receive a discharge diagnosis of costochondritis. Although the discharge diagnosis is not life threatening or considered very serious, the physician utilized high cognitive resources during the ED visit to determine the final diagnosis. According to Medicare.gov, &ldquomedically necessary&rdquo is defined as &ldquohealth-care services or supplies needed to prevent, diagnose, or treat an illness, injury, condition, disease, or its symptoms and that meet accepted standards of medicine.&rdquo Thus, the service should be considered appropriate and medically necessary.

By contrast, Cigna, a large private payer, defines Medically Necessary" or "Medical Necessity" as &ldquohealth care services that a physician, exercising prudent clinical judgment, would provide to a patient. The service must be:

  1. For the purpose of evaluating, diagnosing, or treating an illness, injury, disease, or its symptoms
  2. In accordance with the generally accepted standards of medical practice
  3. Clinically appropriate, in terms of type, frequency, extent, site, and duration, and considered effective for the patient's illness, injury, or disease
  4. Not primarily for the convenience of the patient, health care provider, or other physicians or health care providers
  5. Not more costly than an alternative service or sequence of services at least as likely to produce equivalent therapeutic or diagnostic results as to the diagnosis or treatment of that patient's illness, injury, or disease.

Is Prudent Layperson applicable to managed care plans?

Answer

Federal Law requires that insurance sold on the individual and group markets and group health plans abide by the Prudent Layperson Standard. According to CFR &rsaquo Title 29 &rsaquo Subtitle B &rsaquo Chapter XXV &rsaquo Subchapter L &rsaquo Part 2590 &rsaquo Subpart C &rsaquo Section 2590.715-2719A coverage of emergency services in a group health plan, or a health insurance issuer offering group health insurance coverage, must provide benefits with respect to services in an emergency department of a hospital, and the plan or issuer must cover emergency services

(1) Without the need for any prior authorization determination, even if the emergency services are provided on an out-of-network basis

(2) Without regard to whether the health care provider furnishing the emergency services is a participating network provider with respect to the services

(3) If the emergency services are provided out of network, without imposing any administrative requirement or limitation on coverage that is more restrictive than the requirements or limitations that apply to emergency services received from in-network providers

(4) If the emergency services are provided out of network, by complying with the cost-sharing requirements and

(5) Without regard to any other term or condition of the coverage, other than the exclusion of or coordination of benefits an affiliation or waiting period permitted under part 7 of ERISA, part A of title XXVII of the PHS Act, or chapter 100 of the Internal Revenue Code or applicable cost sharing.

Definition of Emergency Medical Condition. Under the statute, &ldquoemergency medical condition&rdquo means a medical condition manifesting itself by acute symptoms of sufficient severity (including severe pain) so that a prudent layperson, who possesses an average knowledge of health and medicine, could reasonably expect the absence of immediate medical attention to result in placing the health of the individual or, with respect to a pregnant woman, the health of the woman or her unborn child) in serious jeopardy serious impairment to bodily functions and to serious dysfunction of any bodily organ or part.

Applicability date. The provisions of federal law are applicable to group health plans and health insurance issuers for plan years beginning on or after January 1, 2017. Until the applicability date for this regulation, plans and issuers were required to continue to comply with the corresponding sections of 29 CFR part 2590, contained in the 29 CFR, parts 1927 to end, edition revised as of July 1, 2015.

Answer

Federal Law requires that insurance sold on the individual and group markets and group health plans abide by the Prudent Layperson Standard. According to CFR &rsaquo Title 29 &rsaquo Subtitle B &rsaquo Chapter XXV &rsaquo Subchapter L &rsaquo Part 2590 &rsaquo Subpart C &rsaquo Section 2590.715-2719A coverage of emergency services in a group health plan, or a health insurance issuer offering group health insurance coverage, must provide benefits with respect to services in an emergency department of a hospital, and the plan or issuer must cover emergency services

(1) Without the need for any prior authorization determination, even if the emergency services are provided on an out-of-network basis

(2) Without regard to whether the health care provider furnishing the emergency services is a participating network provider with respect to the services

(3) If the emergency services are provided out of network, without imposing any administrative requirement or limitation on coverage that is more restrictive than the requirements or limitations that apply to emergency services received from in-network providers

(4) If the emergency services are provided out of network, by complying with the cost-sharing requirements and

(5) Without regard to any other term or condition of the coverage, other than the exclusion of or coordination of benefits an affiliation or waiting period permitted under part 7 of ERISA, part A of title XXVII of the PHS Act, or chapter 100 of the Internal Revenue Code or applicable cost sharing.

Definition of Emergency Medical Condition. Under the statute, &ldquoemergency medical condition&rdquo means a medical condition manifesting itself by acute symptoms of sufficient severity (including severe pain) so that a prudent layperson, who possesses an average knowledge of health and medicine, could reasonably expect the absence of immediate medical attention to result in placing the health of the individual or, with respect to a pregnant woman, the health of the woman or her unborn child) in serious jeopardy serious impairment to bodily functions and to serious dysfunction of any bodily organ or part.

Applicability date. The provisions of federal law are applicable to group health plans and health insurance issuers for plan years beginning on or after January 1, 2017. Until the applicability date for this regulation, plans and issuers were required to continue to comply with the corresponding sections of 29 CFR part 2590, contained in the 29 CFR, parts 1927 to end, edition revised as of July 1, 2015.

How do I assure that the medical necessity for treatment in the emergency department is identified for billing?

Answer

Here is where the problem often lies. Payers look for an &ldquoemergency&rdquo condition to determine medical necessity for payment and their definition of &ldquoemergency condition&rdquo may determine whether or not the visit is paid in full or even at a lower payment level. Often, the presenting problem looks like an emergency condition but, after a medically necessary work up, the final diagnosis does not appear to support an emergency condition according to the payer policy. Identifying the presenting problem and/or chief complaint on billing forms may better describe the problem that caused the patient to seek emergency treatment. However, according to ICD-10, &ldquocodes that describe symptoms and signs, as opposed to diagnoses, are acceptable for reporting purposes when a diagnosis has not been established (confirmed by) the provider. When a diagnosis is confirmed, it is technically inaccurate to add on the chief complaint, signs and symptoms. There is difficulty in providing &ldquoaccurate&rdquo coding per the ICD-10 rules and identifying the problem when a final diagnosis is made.

In the example above, the patient who arrived with &ldquoatypical chest pain&rdquo (R07.89) and diagnosed with costochondritis (M94.0) would be coded with ONLY the costochondritis and not the chest pain which provides the medical necessity for the extensive diagnostic treatment to rule out a cardiac event.

It is important to document and code medical necessity for each step in the medical decision-making process, including diagnostic studies and ancillary services. Co-morbidities and risk factors provide additional details to support medical necessity for evaluation and management of the patient.

For those payers who look to the final diagnosis on the claim form to determine the appropriateness of emergency department care, it may be in the emergency providers best interest to include the codes for signs and symptoms to provide enough information to allow the payer to make appropriate decisions about payment.

  1. State-by-State listing of EMC language: https://publichealth.gwu.edu/departments/healthpolicy/CHPR/nnhs4/GSA/Subheads/gsa116.html
  2. Prudent Layperson article:https://www.ahcmedia.com/articles/48670-congress-adopts-prudent-layperson-standard-for-medicare-medicaid-enrollees.
  3. Emergency Medical Treatment and Labor Act (EMTALA), Centers for Medicare and Medicaid Services, http://www.cms.gov/Regulations-and-Guidance/Legislation/EMTALA/index.html
  4. Cigna Definition of Medically Necessary: https://www.cigna.com/health-care-providers/coverage-and-claims/policies/medical-necessity-definitions.
  5. ACEP EMTALA Fact Sheet: http://newsroom.acep.org/2009-01-04-emtala-fact-sheet.
  6. Private Payer Coverage of Prudent Layperson, https://www.medicaid.gov/Federal-Policy-Guidance/downloads/smd040500.pdf.
  7. Federal Prudent Layperson Standard: https://www.law.cornell.edu/cfr/text/29/2590.715-2719A.
Answer

Here is where the problem often lies. Payers look for an &ldquoemergency&rdquo condition to determine medical necessity for payment and their definition of &ldquoemergency condition&rdquo may determine whether or not the visit is paid in full or even at a lower payment level. Often, the presenting problem looks like an emergency condition but, after a medically necessary work up, the final diagnosis does not appear to support an emergency condition according to the payer policy. Identifying the presenting problem and/or chief complaint on billing forms may better describe the problem that caused the patient to seek emergency treatment. However, according to ICD-10, &ldquocodes that describe symptoms and signs, as opposed to diagnoses, are acceptable for reporting purposes when a diagnosis has not been established (confirmed by) the provider. When a diagnosis is confirmed, it is technically inaccurate to add on the chief complaint, signs and symptoms. There is difficulty in providing &ldquoaccurate&rdquo coding per the ICD-10 rules and identifying the problem when a final diagnosis is made.

In the example above, the patient who arrived with &ldquoatypical chest pain&rdquo (R07.89) and diagnosed with costochondritis (M94.0) would be coded with ONLY the costochondritis and not the chest pain which provides the medical necessity for the extensive diagnostic treatment to rule out a cardiac event.

It is important to document and code medical necessity for each step in the medical decision-making process, including diagnostic studies and ancillary services. Co-morbidities and risk factors provide additional details to support medical necessity for evaluation and management of the patient.

For those payers who look to the final diagnosis on the claim form to determine the appropriateness of emergency department care, it may be in the emergency providers best interest to include the codes for signs and symptoms to provide enough information to allow the payer to make appropriate decisions about payment.

  1. State-by-State listing of EMC language: https://publichealth.gwu.edu/departments/healthpolicy/CHPR/nnhs4/GSA/Subheads/gsa116.html
  2. Prudent Layperson article:https://www.ahcmedia.com/articles/48670-congress-adopts-prudent-layperson-standard-for-medicare-medicaid-enrollees.
  3. Emergency Medical Treatment and Labor Act (EMTALA), Centers for Medicare and Medicaid Services, http://www.cms.gov/Regulations-and-Guidance/Legislation/EMTALA/index.html
  4. Cigna Definition of Medically Necessary: https://www.cigna.com/health-care-providers/coverage-and-claims/policies/medical-necessity-definitions.
  5. ACEP EMTALA Fact Sheet: http://newsroom.acep.org/2009-01-04-emtala-fact-sheet.
  6. Private Payer Coverage of Prudent Layperson, https://www.medicaid.gov/Federal-Policy-Guidance/downloads/smd040500.pdf.
  7. Federal Prudent Layperson Standard: https://www.law.cornell.edu/cfr/text/29/2590.715-2719A.
Disclaimer

The American College of Emergency Physicians (ACEP) has developed the Reimbursement & Coding FAQs and Pearls for informational purposes only. The FAQs and Pearls have been developed by sources knowledgeable in their fields, reviewed by a committee, and are intended to describe current coding practice. However, ACEP cannot guarantee that the information contained in the FAQs and Pearls is in every respect accurate, complete, or up to date.

The FAQs and Pearls are provided "as is" without warranty of any kind, either express or implied, including but not limited to, the implied warranties of merchantability and fitness for a particular purpose. Payment policies can vary from payer to payer. ACEP, its committee members, authors or editors assume no responsibility for, and expressly disclaim liability for, damages of any kind arising out of or relating to any use, non-use, interpretation of, or reliance on information contained or not contained in the FAQs and Pearls. In no event shall ACEP be liable for direct, indirect, special, incidental, or consequential damages arising out of the use of such information or material. Specific coding or payment related issues should be directed to the payer.


Prudent

“To say we can issue billions of dollars in debt on a moment’s notice and take on a system for which we have no means to pay for is not fiscally or service prudent ,” Cate said.

Under federal law, she said, construction may harm the island only if there is no “ prudent or feasible” way to avoid it.

Like Andrew Cuomo, he might have been prudent to let the crisis play out before penning a book.

It’s not official yet, and it certainly doesn’t mean people shouldn’t continue to take prudent public safety measures such as wearing masks and social distancing.

Deep cleaning public places such as subway cars seemed prudent early on, but evidence suggests that touching shared surfaces isn’t a big driver of transmission events, Klimek says.

In addition, he had made prudent investments and, except for his wine cellar, did not live lavishly.

There was no way to test blood for HIV, and excluding gays was a prudent move.

Bicycle riders are prudent to fear being clipped by a passing car.

It was the result of a chain of good decisions—wise, prudent , long-sighted, or, at the least, expedient choices.

It is, rather famously, not the most prudent move to get a Ph.D in philosophy.

If they had only been able to learn from the licentiate Alcaraz, who was experienced and very prudent !

But being himself in somewhat strained relations with the existing Government, he did not think it prudent to show himself.

On his departure from the Alcazar, the warden thought it prudent to send a person to observe his movements.

I being, he considered, the more prudent in money matters, kept our lodging accounts and paid the bills.

The commander-in-chief overrated the fighting qualities of the Neapolitan troops and thought it prudent to evacuate Rome.


History

It was easy to lose hope in 1977. Still recovering from the gas crisis, the economy had recently suffered successive years of double-digit market losses and double-digit inflation. Unemployment was the highest since the Great Depression.

Feverishly typing in a one-bedroom apartment was a man with hope. Clack–clack–clack, hammering the typewriter keys. Then a mistake. Back-back-back, retyping over the error with correction tape. Again, clack-clack-clack, thoughts committed to paper. Hours passed and it was complete.

On a March morning in 1977, Al Frank left his apartment with the first edition of The Prudent Speculator, at the time dubbed The Pinchpenny Speculator. Four pages, double-spaced. No electronic backups in those days, it was the only copy. Death-gripping his four sheets of paper, Al Frank headed to the copy shop and manually set them on the copier, waiting for page after page to come through the machine. All that labor for just 100 copies and the hope that they would catch on.

This is how you behave when you believe something at your core.

Al Frank, a relentless bargain hunter who believed in a diversified portfolio of undervalued stocks, began delivering his message in four pages, double-spaced, and just 100 copies.

His core belief came to life. Readers became subscribers, subscribers became callers, and gradually those callers, family, and friends asked Al to manage their portfolios

For ten years of growth, all is well. The firm has grown to just under 20 employees and hires a Computer Science student from the University of Southern California to assist in automating the office. John Buckingham was previously employed as a cold caller by a broker, where he would ride his bike 4 miles to work and keep his dress shirt and tie in his backpack. After John realized that cold calling was not his calling, the broker referred John to Al Frank and associates where he made $8 per hour learning about stock analysis and portfolio management, in addition to accounting and subscriptions.

Then unsettling news erupts. Monday begins with a market crash in Hong Kong. Panic spreads and devastates European markets. U.S. markets open and lose 22% of their value. The date is October 19, 1987 – Black Monday.

Pandemonium sets in. Phones ringing and ringing. The same message with every call: “Sell-sell-sell.” Overwhelmed by calls, Al Frank shouts, “John, get on the phone and calm these people down!”

As the market slowly recovers, Al discovers John has a natural talent for investing. On the side, John’s trips to Vegas and penchant for mathematics get him interested in turning a small sum into a large sum, in Black Scholes analytics, and in options. He begins to invest in that which he believes is mis-priced. He starts focusing his IT skills on investing and writing programs to find bargain stocks with better speed and precision.

Over time, Al Frank Asset Management became AFAM Capital. The investment team expanded, proprietary funds were formed and Innealta Capital was acquired (at a bargain of course).

Al Frank passed away in 2002, leaving a legacy that started as a labor of conviction in 1977. Just four pages, double-spaced and 100 copies revealed the benefits of value investing.

Experts noticed. Mark Hulbert and The Hulbert Financial Digest ranked The Prudent Speculator newsletter #1 * . Others like Bloomberg and CNBC have noticed as well. Fox Business even said “for 15 years, you’ve quietly beat Buffett’s record… ** ”

Recently, John Buckingham was on a press tour in New York City. The PR agent offered to order a town car to take them on their various stops around the city (CNBC, Bloomberg, et al). John replied, “No, let’s take the subway.” Then he stopped at a hot dog stand for lunch. What can we say – old habits die hard. We are relentless bargain hunters. It’s at our core.

On October 1st, 2018, AFAM Capital along with The Prudent Speculator were acquired by Kovitz Investment Group. No changes were made to the individuals involved in writing and delivering Newsletter content to its loyal followers. Kovitz is a wealth management firm with a multitude of services whom recently was ranked number 37 in Barron’s Top 50 RIA list.


Prudent PG-96 - History

This web site is designed to notify citizens when a development application is submitted to the Planning Department, Prince George’s County, Maryland. By clicking on the link below users will be asked to enter their contact information, select a login and password and select one or more zip codes they wish to be notified when a development application is submitted. Once a week users will be notified when a development application has been submitted. If the development property is located within the zip code(s) selected by registered users, a notification email will be sent. The email subject line will be: "Development Notification Prince George’s County, Maryland". Once the user has added their contact information, future emails will be delivered to the user’s email inbox. Users are encouraged to check their Junk folder for this email.

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Case Number | Case Title | Case Description | Case Location | Zip Code | Map Link
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Adherence to the Western, Prudent, and Mediterranean dietary patterns and chronic lymphocytic leukemia in the MCC-Spain study

Diet is a modifiable risk factor for several neoplasms but evidence for chronic lymphocytic leukemia (CLL) is sparse. Previous studies examining the association between single-food items and CLL risk have yielded mixed results, while few studies have been conducted on overall diet, reporting inconclusive findings. This study aimed to evaluate the association between adherence to three dietary patterns and CLL in the multicase-control study (MCC-Spain) study. Anthropometric, sociodemographic, medical and dietary information was collected for 369 CLL cases and 1605 controls. Three validated dietary patterns, Western, Prudent and Mediterranean, were reconstructed in the MCC-Spain data. The association between adherence to each dietary pattern and CLL was assessed, overall and by Rai stage, using mixed logistic regression models adjusted for potential confounders. High adherence to a Western dietary pattern (i.e. high intake of high-fat dairy products, processed meat, refined grains, sweets, caloric drinks, and convenience food) was associated with CLL [ORQ4 vs. Q1=1.63 (95%CI 1.11 2.39) P-trend=0.02 OR 1-SD increase=1.19 (95%CI: 1.03 1.37)], independently of Rai stages. No differences in the association were observed according to sex, Body Mass Index, energy intake, tobacco, physical activity, working on a farm, or family history of hematologic malignancies. No associations were observed for Mediterranean and Prudent dietary patterns and CLL. This study provides the first evidence for an association between a Western dietary pattern and CLL, suggesting that a proportion of CLL cases could be prevented by modifying dietary habits. Further research, especially with a prospective design, is warranted to confirm these findings.

Copyright© 2018 Ferrata Storti Foundation.

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Association between adherence to dietary…

Association between adherence to dietary patterns and chronic lymphocytic leukemia in the multicase-control…


Firm History

In 1992, Philip A. Thayaparan, PE, and Cletus O. Ezenwa, PE, founded a partnership, &ldquoPrudent Engineering Group,&rdquo to provide a brand of engineering consulting services committed to quality of service, professionalism, and client satisfaction. As a DBE/MBE-certified company, the growth and reputation of our firm have since derived from a highly qualified staff known for its technical acumen, project efficiency, and well-rounded expertise.

Initially specializing in civil engineering design and construction inspection services, we broadened the scope of our professional services in 1998 with the addition of Michael J. Wright, LS, as Land Surveying partner. With a professional survey and mapping division established, the firm&rsquos structure was changed to a Limited Liability Partnership.

Headquartered in East Syracuse, New York, we maintain New York offices in Albany, Binghamton, Buffalo, Rochester, Staten Island (NYC), Pittsburgh and Philadelphia, Pennsylvania, and Baltimore, Maryland. With these supporting branch offices, Prudent is strategically positioned to provide clients with cost-effective engineering, inspection, and survey services from multiple locations. Supported by a team of licensed engineers and surveyors, inspectors, drafters, and support professionals, we strive to build lasting business relationships and deliver first-rate project results.

In early 2017, the two principals agreed to an amicable separation with Mr. Thayaparan becoming majority owner and principal-in-charge. Prudent remains committed to the same high principles that branded the company when it first started in 1992.


Prudent public health intervention strategies to control the coronavirus disease 2019 transmission in India: A mathematical model-based approach

Background & objectives: Coronavirus disease 2019 (COVID-19) has raised urgent questions about containment and mitigation, particularly in countries where the virus has not yet established human-to-human transmission. The objectives of this study were to find out if it was possible to prevent, or delay, the local outbreaks of COVID-19 through restrictions on travel from abroad and if the virus has already established in-country transmission, to what extent would its impact be mitigated through quarantine of symptomatic patients?

Methods: These questions were addressed in the context of India, using simple mathematical models of infectious disease transmission. While there remained important uncertainties in the natural history of COVID-19, using hypothetical epidemic curves, some key findings were illustrated that appeared insensitive to model assumptions, as well as highlighting critical data gaps.

Results: It was assumed that symptomatic quarantine would identify and quarantine 50 per cent of symptomatic individuals within three days of developing symptoms. In an optimistic scenario of the basic reproduction number (R0) being 1.5, and asymptomatic infections lacking any infectiousness, such measures would reduce the cumulative incidence by 62 per cent. In the pessimistic scenario of R0=4, and asymptomatic infections being half as infectious as symptomatic, this projected impact falls to two per cent.

Interpretation & conclusions: Port-of-entry-based entry screening of travellers with suggestive clinical features and from COVID-19-affected countries, would achieve modest delays in the introduction of the virus into the community. Acting alone, however, such measures would be insufficient to delay the outbreak by weeks or longer. Once the virus establishes transmission within the community, quarantine of symptomatics may have a meaningful impact on disease burden. Model projections are subject to substantial uncertainty and can be further refined as more is understood about the natural history of infection of this novel virus. As a public health measure, health system and community preparedness would be critical to control any impending spread of COVID-19 in the country.

Keywords: COVID-19 deterministic model mathematical model mitigation quarantine Airport screening transmission.


Prudent PG-96 - History

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Prudent Markets Predicts that Electronic Device History Record (eDHR) Software Market was valued USD xxxx unit in 2020 and is expected to reach USD xxxx Unit by the year 2025, growing at a CAGR of xx% globally.
Global Electronic Device History Record (eDHR) Software Market Overview:
Global Electronic Device History Record (eDHR) Software Market Report 2020 comes with the extensive industry analysis of development components, patterns, flows and sizes. The report also calculates present and past market values to forecast potential market management through the forecast period between 2020-2025.This research study of Electronic Device History Record (eDHR) Software involved the extensive usage of both primary and secondary data sources. This includes the study of various parameters affecting the industry, including the government policy, market environment, competitive landscape, historical data, present trends in the market, technological innovation, upcoming technologies and the technical progress in related industry.

Impact of COVID-19 on Electronic Device History Record (eDHR) Software Market
Since the COVID-19 virus outbreak in December 2019, the disease has spread to almost every country around the globe with the World Health Organization declaring it a public health emergency. The global impacts of the coronavirus disease 2019 (COVID-19) are already starting to be felt, and will significantly affected the Electronic Device History Record (eDHR) Software market in 2020.

Global Electronic Device History Record (eDHR) Software Market Segmentation
By Type, Electronic Device History Record (eDHR) Software market has been segmented into:
Cloud-Based eDHR Software
On-Premise eDHR Software

By Application, Electronic Device History Record (eDHR) Software market has been segmented into:
Medical and Pharmaceutical
Industrial
Manufacturing

Regional Analysis:
North America (U.S., Canada, Mexico)
Europe (Germany, U.K., France, Italy, Russia, Spain etc.)
Asia-Pacific (China, India, Japan, Southeast Asia etc.)
South America (Brazil, Argentina etc.)
Middle East & Africa (Saudi Arabia, South Africa etc.)

Top Key Players Covered in Electronic Device History Record (eDHR) Software market are:
MasterControl
Siemens Industry Software
LZ Lifescience
Engineering USA
42Q
Idhasoft
DATANINJA
Dataworks
Automated Control Concepts
Engineering USA

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