Emergency Room

Emergency Care

In an emergency, get care from the closest hospital that can help you.

• By federal law, the ER must examine you and stabilize your condition whether or not you have insurance or can pay. You'll still get a bill.

♦ Emergency rooms are the best place for treating severe and life-threatening conditions. They're open 24 hours a day, seven days a week.

They have the widest range of services for emergency after-hours care, including diagnostic tests and access to specialists.

That specialized care also makes it the most expensive type of care. And you'll probably have to wait a long time to get treated.

• Freestanding emergency rooms are ERs that aren't attached to a hospital. They often look like urgent care clinics, right down to the strip mall location, but they bill like a hospital ER. In a real emergency they can help, but don't mistake one for a cheaper urgent care clinic.

Your insurance protections

♦ In a real emergency, go to the nearest hospital, in network or not. Federal law protects you:

• Your insurer has to decide whether it was an emergency based on your symptoms, not your final diagnosis. Chest pain that turns out to be heartburn still counts.

• Your plan can't require approval before emergency care, and it can't charge you higher copays or coinsurance because the hospital is out of network.

♦ In 2017, Anthem, which sells Blue Cross Blue Shield plans in many states, made waves when it announced it wouldn't pay for ER visits it decided weren't true emergencies. After a lot of outcry, Anthem added exceptions. Under federal law, insurers have to judge an emergency by your symptoms, not the final diagnosis.

♦ In an emergency room you might be seen by several specialists. Your X-rays or scans might even be read by a doctor in another part of the country. In the past, that meant surprise bills from doctors who weren't in your network.

The No Surprises Act, signed in 2020 and in effect since January 1, 2022, put a stop to most of that. For emergency care, out-of-network hospitals and doctors generally can't bill you more than your in-network costs. It also protects you from surprise bills from out-of-network doctors when you're treated at an in-network hospital.

• The No Surprises Act works alongside state surprise billing laws. It doesn't replace them.

♦ One big exception: ground ambulances. A trip by ground ambulance isn't covered by the No Surprises Act, so you could still get a surprise bill. Air ambulances are covered. Some states have their own ambulance protections.

When to choose an emergency room

Symptoms best evaluated in an emergency room include:

• Weakness or numbness on one side, face drooping or slurred speech (signs of a stroke)

• Fainting

• Change in mental state

• Heavy bleeding

• Large wounds

• Chest pains

• Burns

• Head injuries

• Difficulty breathing

• Broken bones

• Serious allergic reactions

• Seizures

• Flu or cold symptoms with trouble breathing, chest pain or confusion

• A fever in a baby under 3 months old

♦ If you're uncertain, call your plan's nurse hotline for advice (most plans provide this as a free 24-hour service).

► Trust your feeling. If your intuition tells you it's serious, don't hesitate. Go to the nearest emergency room.

Advantages of a hospital emergency room

Hospital emergency rooms provide care at any time, day or night.

They have the staff and equipment to handle the most complicated and critical health issues, including everything from heart attacks and strokes to injuries from a car accident.

Some types of treatment, such as surgery, are only available in a hospital setting.

Do I need to call my insurance company first?

In a true emergency, go straight to the hospital.

Insurers can't require you to get prior approval before getting emergency room services, even from a provider or hospital outside your plan's network.

Will I have to pay anything?

This depends on the plan you chose and the hospital you go to.

Many plans sold on the Marketplace have shifted a lot of the emergency room costs to the patient. Read your plan's Summary of Benefits and Coverage (SBC) carefully.

Most plans now require that your annual deductible be met first before they'll pay anything.

If you've met your deductible, you'll most likely have coinsurance of 20% or more. Gone are the days when you could pay a $75 copay and go home to recover.

• You can be sure someone from the hospital staff will visit your bed before you leave to give you the bad news.

Often someone will ask you to pay something before you leave. You can refuse to pay on the spot.

• Instead, ask them to send you a bill.

Then wait for your insurance company to sort out the bills.

♦ If you pay on the day you visit and later learn you overpaid, it's almost always a very long and nerve-wracking process to get your money back.

• When the bill comes, ask for an itemized bill and compare it to your insurer's Explanation of Benefits (EOB).

♦ If you don't have insurance or can't afford the bill, ask the hospital about its financial assistance (sometimes called charity care) program. Most hospitals are nonprofits, and they're required to have one. Ask before the bill goes to collections.

Summary

Hospital emergency rooms provide medical care at any time, day or night. Unlike urgent care centers or walk-in clinics, they're equipped and staffed for even the most complex and critical needs.

Emergency rooms are the best place for treating severe and life-threatening conditions.

For more, see Urgent Care and Where to Receive Care?