Health Insurance and Emergency Room Coverage

Have you noticed that emergency rooms began popping up in neighborhoods like Starbucks or 7-Elevens over the past couple of years? They promise you’ll be seen quickly with little or no wait time and health insurance should cover it, even if it’s out of network, since it’s an emergency room visit, right? It turns out, that may not be the case.

Blue Cross Blue Shield of Texas announced in April they would not pay for emergency room visits they were not considered serious or life threatening. The change in policy took place on June 4th. BCBS was concerned policy holders were going to an emergency room for things like head lice and sprained ankles resulting in very expensive medical bills that drive up the cost of health care and health insurance.

Anthem, a large health insurer, was recently sued by The American College of Emergency Physicians and the Medical Association of Georgia for declining to pay for some emergency room. The question raised is how hard can a health insurance company push patients to seek lower cost care and at whose expense?

There are enough differences between these two cases to dismiss them as unrelated, however, there is an interesting commonality between the two as it relates to the cost of emergency room care. It’s some of the most expensive care one can have, and it will cost much less to treat lice or a sprained ankle through an in-network clinic or primary care physician than it would in an ER. In addition, they both raise a couple of questions worth exploring here.

  • When should a patient seek treatment at an emergency room?
  • What constitutes a serious medical condition?
  • Which ERs and clinics are part of the network?
  • If you’re involved in a potentially life-threatening accident and taken to an ER that’s out of network, will it be covered?

In some cases, it’s easy to define many life-threatening conditions, but how do you define “serious?” BCBS states on their website, patients should use an ER when they are having heart or breathing problems, heavy bleeding, broken bones, or severe pain. They also state that a clinic or primary care physician should be used for a cold, sore throat, or flu symptoms, ear or sinus pain, rashes, cuts that don’t need stitches, constipation, and tolerable pain.

Knowing which ERs or clinics are in network and which ones are not in network should be one of the first things patients look at before heading out the door to seek care. That’s not always the case though. Further complicating the issue is that even if the ER or clinic is in network, there may be some physicians who work there who aren’t in network.

One last issue that no one seems to address is not all ERs are trauma centers. Should a patient who’s experienced life-threatening trauma be routed to an ER that’s not a trauma center, but in network or to an out of network trauma center that’s better suited to provide the level of care needed for a specific level of trauma?

I do believe patient’s need to be more involved in selecting appropriate treatment for their medical needs, but this requires better education and access to information than many people are getting. What do you think? Share your thoughts, questions, and experiences with me on my Facebook, Google +, or LinkedIn pages. I’d love to hear from you!

Evie Wise
Evie Wise


Evie Wise
Evie Wise

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