With the rise of freestanding emergency rooms in Texas comes the rise of questions and concerns about how they operate. Many of these concerns manifest from the financial operations of freestanding ERs. The high insurance deductibles and co-pays following a visit to a freestanding ER have resulted in a significant backlash from customers.
In order to alleviate the frustrations that many have expressed, we constructed a Q&A about the common questions that previous customers had for us about their insurance coverage, including information on deductibles, copays, networks and Medicare.
What insurance carriers are accepted?
What insurance carriers are accepted depends on which freestanding emergency room administers your treatment. Most freestanding emergency rooms work with all private insurance companies such as Blue Cross Blue Shield, Humana, Aetna, UnitedHealth, and many others. If the freestanding emergency room is associated with a hospital system, they can accept Medicare or Medicaid. However, all other freestanding emergency rooms not associated with hospital systems are prohibited to accept Medicare or Medicaid.
How do deductibles and copays work at an ER? What am I expected to pay at the time of service?
At the time of service, you are expected to provide your copay. Your deductible, along with co-insurance and other services that were not covered by your insurance, will be billed to you as your “balance due,” which you will receive a few days or weeks after your treatment. Your deductible usually renews every calendar year and signifies the amount you must pay before your insurance takes over your medical bills. As a result, your bill might be larger than you expect if you have a high deductible or have not had any health expenses for the year.
Am I going to be paying out-of-network or in-network?
Texas Insurance Law requires that all fully-funded medical insurance plans treat every emergency claim as in-network. The burden of proof, however, falls on your emergency room; if the ER chooses not classify your treatment as a “medical emergency,” you might have trouble getting your insurance to consider it in-network. In that case, many plans will pay 80 percent of your in-network costs and 50 percent of your out-of-network costs.
If your health insurance company attempts to treat your classified medical emergency as out-of-network, you can consider it a violation of law and take action by contacting your billing company or your insurance agent.
What if I don’t have medical insurance? Can I still be treated?
If you can’t afford private insurance and don’t qualify for Medicare or Medicaid, the Affordable Care Act (ACA) will help you get health insurance at an affordable cost. After enrollment, the ACA is designed to eliminate uninsured risks by providing insurance options for everyone. If you remain uninsured, Texas law dictates that you can go to any federally-sanctioned emergency room and receive treatment.
Despite popular belief, freestanding emergency rooms operate in the same way that hospital emergency rooms do, which means they operate under the same laws and requirements. If your condition is deemed an emergency, uninsured patients will not be turned away from hospital or freestanding emergency rooms, and many ERs will work out payment plans to accommodate uninsured patients.
Do freestanding ERs take Medicare?
As previously mentioned, freestanding ERs not associated with hospital systems cannot accept Medicare, Medicaid or Tricare, according to the state of Texas. Also, it’s important to understand that Medicare is a federal program for those over 65 (no matter what your income is), while Medicaid is a state and federal program that provides health coverage if you have a low income. They do accept insurance under the ACA, however.
What do I do if I have a question about my insurance bill or claim?
If you have a question about your insurance bill or claim, you can contact your emergency room’s billing company or the emergency room you visited, or direct your questions to your insurance agent. Both of those liaisons are designated to help you with any questions or concerns that you might have regarding your insurance. Your insurance agent will more than likely be able to help you address any questions you have about your policy, while the emergency room billing company will be able to help you with any problems you might have with your bill.
Select freestanding emergency rooms have patient advocates that act as a liaison between the insurance company and the patient. This makes the billing process far less stressful for the patient, and allows their bill to be broken down and explained easily by the advocate. It’s the advocate’s responsibility to contact the ER you visited to ensure you are being billed the correct amount.
Why aren’t all services covered by my insurance carrier?
This depends on how the emergency room documents the patient’s conditions and how the insurance company classifies those conditions. A big factor that health insurance companies consider when determining which services are covered is if your condition is a true emergency or not. To make sure you are being billed for the correct services, communicate with the emergency room. Patients often leave emergency rooms without knowing how much the services they received cost and what’s covered by insurance, which causes confusion and frustration.
If you are unsure about your emergency healthcare insurance coverage, call your insurance company or emergency room patient advocate with any detailed questions. Contacting the emergency room or their patient advocate with any questions regarding your bill, co-pay or deductible is also a good idea.