Health Plan Rules: What Counts As an Emergency?

By Tom Murphy, AP Business Writer

When is an emergency not an emergency? In health care, that can be a costly distinction.

Emergency rooms are designed to live up to their names by treating life-threatening or serious medical problems. But they often handle much more than that, sometimes at great cost to patients.

About 17% of all emergency department visits could take place at less expensive alternatives such as retail clinics and urgent care centers, according to a study published last fall in the journal Health Affairs. Switching those ER visits to the alternatives could save more than $4 billion annually.

Health insurers are keenly aware of this, and they want patients to consider other options. WellPoint Inc., which runs Blue Cross Blue Shield plans in several states, has launched a website to help customers find emergency room alternatives. UnitedHealth Group Inc. offers a free smart phone application that locates urgent care centers.

But choosing an ER alternative isn't a simple decision, especially when a sudden health concern hits. Here are some things to consider:

Why do health insurers want you to avoid the emergency room?

ER visits are not cheap. Insurers may see a bill of $580, depending on the location, for a case of strep throat treated in an emergency room, according to WellPoint. In contrast, an urgent care clinic may charge $90 and a retail health clinic (think Walgreens or CVS) might ask for only $40.

Emergency rooms come with many expenses. They have to be open every day, around the clock. They're staffed with doctors, nurses and technicians.

They must be equipped for anything.

Even if a patient visits one with a condition that turns out to be relatively minor, doctors there are obligated to rule out something more serious. That means they have to make sure the flu bug that left you nauseated and vomiting isn't really appendicitis.

"The chance of you getting some tests which are going to increase your costs are pretty high in the emergency room simply because of the way we're set up and the standard to which we're held," said Dr. William T. Durkin Jr., vice president of the American Academy of Emergency Medicine.

Why should this cost difference matter to patients?

Insurers aren't the only ones who will pay more. Patients can face co-payments of $100 or more for using an emergency room. They also may wind up with a big bill if they have a high-deductible plan that makes them pay more than the typical plan out of pocket.

Patients also may run into problems getting coverage for parts of their claim. Hospitals are required to evaluate and stabilize people who come into the emergency room, and most insurance plans will cover this, said Dr. Michael D. Bishop of the American College of Emergency Physicians.

But they may balk at paying for a claim that could have been handled elsewhere even though it seemed like an emergency at first. This might involve a child who arrives at the ER with a high fever and winds up being treated for an ear infection, not meningitis.

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