Most health insurers now impose a very high co-payment (average $250.00) for emergency department (ED) visits. While I understand the need to deter “inappropriate” ED usage, this policy can result in adverse outcomes for individuals who may delay seeking emergency care because of high co-pays. Regardless, the onus now rests on the individual to decipher emergency from non-emergency and to make “appropriate” decisions. A “health emergency” is oftentimes very subjective – it’s how you experience what you experience; it tends to be emotionally charged and most lay individuals are afraid to wait -because they fear the worse if they do. In order to mitigate “inappropriate” ED usage most health insurance companies now have 24/7 Nurse Advice Lines that consumers can call if they feel they’re experiencing an emergency – the nurse may advise the consumer to go to the ED or to activate emergency medical services. Consumers are also expected to contact their general practitioner if it’s during business hours or use urgent care centers. Regardless, health care consumers are now expected to cultivate the practice of going through least expensive options before going to the ED.
If you decide on the ED, most hospital providers are now proactively collecting the ED co-pay during health encounters for fear of incurring a financial loss; one cannot blame them because healthcare is also a business – organizations are in it to make a profit. Healthcare consumers should be aware that there is a federal law that protects individuals’ rights to emergency care. The hospital can and will send a bill; make no mistake about that. Hospitals also stand to lose millions of dollars because not everyone can come up with $250 ED co-pay –especially not when they’re experiencing a health crisis.
My youngest sister shared this horrendous experience about her health insurance coverage when she became suddenly ill and needed emergency care; for full disclosure, she’s well versed in the health insurance business because it’s central to her work with a large not- for- profit hospital-based healthcare system. Her employer is self-insured with a preferred provider network that employees are to use at all times; also, there is an option to access out- of -network providers but the cost share is prohibitive. On the day in question, my sister started vomiting incessantly with stomach cramping; after several hours with no relief she decided to go to an urgent care center hoping to avoid the ED visit co-pay. The urgent care center providers called an ambulance because they were ill-equipped to treat her but my sister refused the ambulance ($500+ – cost) out rightly and decided to drive herself.
She pulled over several times due to uncontrollable vomiting; on arrival, the ED personnel were waiting to receive her because they had received prior notification regarding her condition. My sister was asked for her co-pay ($250) even as she was being assessed; she made the co-pay. She was treated with fluids and medications for the vomiting all of which she monitored and asked whether they will be part of one bill or charged separately. She was discharged and readmitted inpatient because she was still medically unstable; the charges started anew. My sister refused to see a gastro intestinal specialist inpatient because she knew she would be charged separately and at a higher rate; she opted for the hospitalist (in-patient physician) and planned to do all specialists appointments and special procedures as an outpatient. During this entire experience my sister was completely preoccupied with managing cost at the expense of focusing on her health and recovery. Thank God she came through without any adverse health outcomes but it was an extremely stressful experience and no one should be worrying about this micro level of self-case management during a health crisis.
Similarly, a work colleague brought her 12 year old daughter to the emergency department after four hours of projectile vomiting and abdominal cramping. The child was treated with fluids and medications for the vomiting. The hospital also did some lab tests and discharged my colleague and her daughter after test results were declared normal (approximately four hours). The hospital bill totaled over $2,000 and my colleague received a call from the hospital the very next day requesting her ED co-pay of $250. My colleague insisted that her visit was an emergency and the hospital directed her to appeal with her health insurance carrier. My colleague filed an appeal with the health insurance and the ED co-pay was waived. According to my colleague, she hesitated before taking her child to the ED because she was fearful of the high ED co-pay. Thankfully our health insurance has an appeals process as opposed to others who must make the co-pay regardless of whether or not the visit was a true emergency.
Recently, I had a health scare that landed me in the ED. I called an ambulance because it was the appropriate thing to do; I needed to make it to the ED sooner than later. There were some collateral benefits to my activating emergency medical services; I had a very positive experience with the female police officer who responded to my call. Also, the paramedics were very knowledgeable and reassuring – even as I signed my life away while they verified my health insurance coverage. I made it safely and received care; however, in the middle of the assessment the registration personnel asked for my co-pay. I retorted “how much?” She replied “$250.00” and I retorted again “I don’t have that kind of money” to which she replied “I have to ask.” I realize that providers should get paid for their services hence the proactive co-pay collection approach. Who can blame them?
My total bill was almost $4,000 and don’t ask why because all I received was emergency transportation (separate bill), a comprehensive physical assessment and a medication script. No blood tests and no fluids given; this is why we must move to a value-based payment system as opposed to just fee-for service. Anyway, the insurance paid their negotiated rate and I’m on the hook for $250 which I have since appealed and awaiting a decision. If the decision is not in my favor I’ll have to pay the hospital; however, if I should get the same experience again, I’ll not hesitate to seek emergency care again!
In my sister’s and my case, the hospital’s policy is to collect the co-pay upfront if possible and in my colleague’s case the hospital’s policy is a bit flexible but still seeks to collect their money immediately afterward. It’s cruel and unrealistic to expect someone experiencing a medical emergency to make clear headed and calculated decisions about an appropriate level of care, micro manage their care while admitted inpatient, or refuse and delay care so they can seek care elsewhere to save money? This is also assuming that the individual is medically and psychiatrically stable to negotiate care.
It’s not clear whether health insurers have evaluated the impact of this specific policy on health care consumers and providers. The health insurance industry’s quest to make a profit cannot and should not be the primary focus when making medical policy decisions. There are real people being impacted by these policies – how about them? Until something is done to overhaul our failing healthcare system, healthcare consumers should become intimately aware of their health insurance coverage policies and appeals processes so they can use them when necessary. Even with all the noise and confusion, do not hesitate to go to the ED or call EMS if you feel you’re experiencing an emergency – that way you’ll live to either fight to improve our current health care system, or benefit from a new and improved one.