This is an attempt to drive people to urgent care centers or doctor’s offices which are less expensive and can save the insured money. Exceptions exist for referrals from a physician to the ER for non ER services, non ER services provided to children under age 14, instances when an urgent care clinic is more than 15 miles away and when care is administered on Sundays and major holidays.
Necessary ER Visits
There is a lot of grey area here but the Affordable Care Act defines an emergency as anything that “a prudent layperson, possessing an average knowledge of medicine and health” would believe to be emergent and in need of immediate attention.
That leaves it to the patient to self-diagnose and then decide which is the most prudent place to go. Of course, it does not help that ER staff and doctors often cannot determine if an ER visit is necessary without examining the patient and possibly performing additional tests to rule out a condition.
While coughs, sore throats, and headaches are usually not emergencies, the reality is that the Journal of American Medicine discovered that six of the top ten reasons for unnecessary ER visits are also in the top ten symptoms of real emergencies!
Before You Head to the ER:
- Try telemedicine or a virtual doctor’s visit. This approach is just beginning to get traction. Many major insurance companies provide this coverage benefit.
- Choose a retail or “nurse in a box” clinic often located in big box or drug stores. The majority have non-business hour availability.
- Check out a faith-based program. This is where participant’s support each other’s medical needs across the country and world by utilizing Medical Cost Sharing Principles.
Before an Emergency Happens – Know Your Policy
Make sure you know what your insurance policy says about emergency care reimbursement and what defines an emergency. This is more important than ever in a world of rising deductibles, higher co-pays and co-insurance, less coverage and increasing premiums.
Do your due diligence before you receive an ER bill and also check the hospital’s financial assistance guidelines. While many folks assume this is only for non-insured or low-income situations, there typically is an option for insured to under-insured patients as well. You must meet their guidelines to qualify.
Determine your emergency care options prior to one occurring. You do not want to worry about finances when involved in a true emergency.