Health plan rules: what counts as an emergency?

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 percent 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.

Medicare, the federal insurance program for the elderly and disabled, is required to cover these cases by applying what’s called the “prudent layperson” standard. That basically means that if a person with normal intelligence seeks treatment in an ER because they think they are having a serious emergency, then Medicare will cover the claim even if it turns out to not be an emergency.

Most insurers will follow this standard for a person who comes to the ER with chest pains and winds up diagnosed with indigestion. But Bishop said coverage can be spotty for other claims, depending in part on the plan.

? What other options are there if you want to avoid an ER visit?

A personal physician or family doctor is a good place to start. But seeing the doctor on short notice can be difficult, and waiting a few days may not be prudent. In those cases, retail clinics and free-standing urgent care centers offer alternatives.

Retail clinics are usually staffed by nurse practitioners in small offices inside another business like a drug store. They can handle relatively minor problems like a sinus infection, bronchitis or the flu.

Urgent care centers can offer extended hours and a deeper level of care. They frequently are staffed by doctors and can handle some broken bones or lacerations. These centers also may have X-ray machines or offer lab tests.

Co-payments can range from $10 to $40 for clinics and urgent care centers, according to WellPoint.

Sometimes there is no alternative to an emergency room if a patient is uninsured, becomes sick in the middle of the night or has no urgent care center or retail clinic nearby.

? When should you head straight to the emergency room without messing around?

Heavy bleeding that won’t stop, severe abdominal pain, a major bone fracture or signs of a stroke like a sudden numbness on one side of the body require emergency attention.

A patient who is over age 30 and having chest pains also should get to the ER rather than Google the nearest retail clinic.