No one really wants to be thinking about health plan rules in the middle of a family emergency. But then again, no one’s ever excited to receive a big unexpected bill for a trip to the ER—especially when it could have been avoided.
The key is to be prepared with knowledge about your health plan before you need it. So if an emergency does come up, you’ll know what to do:
Decide if you really need the emergency room.
Up to 25% of visits made to the ER are not actually emergencies—they are cases of allergies, coughs, or sprains and strains, which could have been treated in the doctor’s office. Yet when treated in the emergency department, the same care can cost three to four times more.
There is also no guarantee you’ll get faster or better service in the ER. Depending on how busy they are, and how urgent your condition is, the average ER wait time can be up to four hours.
Call your plan’s nurse advice line.
Most plans offer this service for free, 24 hours a day. Not sure or want a second opinion? Call back. The benefit is yours, and you’ve paid for it.
Try an urgent care clinic
This is an excellent alternative if your condition is not life threatening but also can’t wait for your regular doctor. While most clinics are not open 24 hours, the costs will be a fourth or a fifth of what an ER would charge.
Also be aware that health plans have varying rules on how they cover urgent care visits, so find out before you go.
If you do need to go to the emergency room:
Avoid the ambulance.
Unless the situation is life-threatening, or a person has a neck or spine injury, you may get care just as quickly in your own car. Ambulance fees can be high, and some plans will not cover them if the situation was not actually an emergency.
What defines as an emergency can be tricky. According to federal regulations, an emergency is what a “prudent layperson” would determine to be a situation requiring emergency attention. But insurance companies don’t always have the same opinion as Joe on the street, and may refuse to pay a claim.
This kind of denial can be appealed, but can be difficult to win. So if the urgency of the situation is unclear, but driving on your own is definitely safe, avoid the ambulance altogether.
Learn your authorization rules.
Some plans require you to notify them before you go to the ER. Others may require that you obtain authorization from your primary care provider first.
Under the health reform bill, newer plans can no longer require prior authorization, but plans that were created before the bill was passed in March 2012 (grandfathered plans) are exempt from this rule.
Question your bill.
Start by asking the hospital for an itemized bill. Go over each of the expenses to see if they look right. For example, multiple charges for the same thing, services that never happened, or incorrect diagnoses.
Since ERs can be chaotic places, with multiple physicians handling one patient, it is not uncommon for a diagnosis to be changed or recorded incorrectly, or for a test to be ordered but never completed.
Be aggressive in asking the hospital about charges that don’t make sense or appealing to the health plan if they refuse to cover certain services.
Beware of balance billing.
Most plans are now required by the health reform bill to cover emergency care at the same cost shares for you, whether the hospital was in-network or out-of-network (grandfathered plans are exempt).
But in situations where a plan does not have a contract with individual physicians staffing the ER, the plan might reimburse physicians at lower rates than the doctors normally charge. So the physicians then turn around and bill their patients the difference—a practice known as balance billing.
Each state has different laws around balance billing when it comes to in-network versus out-of-network providers and HMOs versus PPOs. Find out what the laws are in your state to make sure you are not being improperly billed.