Medical emergencies can arise anytime and anywhere, irrespective of whether you are at home, work or play. Emergency rooms (ERs) provide crucial care for emergencies, but they may also lead to billing pitfalls and coverage issues. When it comes to ER visits, it is essential to understand how they impact your health care coverage, reimbursements, and out of network referrals. In this blog, we will discuss some of the common ER pitfalls that you need to avoid to protect yourself.
Diagnosis key to coverage determination:
The diagnosis codes you receive during your ER visit may impact your coverage or reimbursements. It is important to review your explanation of benefits (EOB) to ensure the diagnosis code used by the hospital is accurate. Because if it isn’t, it could mean a reduction in coverage from your insurance provider. If your diagnosis code is wrong, you can appeal it by submitting a request for a corrected EOB, ensuring that you are paying the right amount by providing the correct diagnosis.
HMO can’t follow up out of area service without out of area referral (gap exception):
There could be instances where you need to visit an ER outside of your network or coverage area. In such cases, you need to obtain an out of area referral (gap exception) from your primary care physician or seek emergency care for life-threatening situations. Without this arrangement, your insurance provider won’t cover your medical expenses, leaving you with a hefty bill. It’s crucial to consult with your health care provider ahead of time to ensure you are aware of the specifics regarding your coverage during emergencies.
In-network vs. out of network visits:
If you visit an in-network hospital, you would receive discounts on the total bill for those services, while an out of network hospital would charge their set fees, which often result in hefty bills. Always ensure that you know the license agreement of your coverage area and familiarize yourself with the in-network and out of network hospitals in proximity to you. Having a well-defined understanding can keep you informed and prepared in emergency situations.
Check with insurance beforehand:
Did you know that your insurance provider may not cover your ER visit, even if you visit an in-network facility? This is because some insurance providers may only cover certain emergency symptoms or treatments specifically related to the emergency condition. It’s best to consult with your insurance provider before seeking care during times of emergencies or to avoid getting stuck with unexpected bills.
Review bills and appeal if necessary:
After your ER visit, it’s essential to review your bill to ensure it is an accurate representation of your treatments and care received. Anything that looks erroneous, including diagnosis codes, treatments, or medications given, should be disputed and appealed accordingly. If you find bills consistent with those of procedures and care that were not a part of your treatment in the hospital, you can dispute the payments and ask for refunds from your insurance provider.
Emergency rooms provide crucial care and support in emergencies, but they also come with pitfalls and coverage issues. By understanding how these visits and different types of care impact insurance reimbursements, coverage, and out of network referrals, you can avoid any unwanted surprises while protecting your pocketbook. Understanding your insurance benefit coverage and regularly reviewing your bills can help you save a significant amount of money while receiving the care you need in times of emergencies. Always remember to consult with your healthcare provider, know your coverage area, know the in-network hospitals, and check with your insurance provider before seeking care.
