Healthcare Reform and the Emergency Room: Will Healthcare Reform Help Me If I Have an Emergency?

We’ve all heard about healthcare reform and rescissions, the interim high-risk health insurance pool, and the health insurance exchanges, but today we thought we would talk a little about how healthcare reform might affect any of us at any time: the emergency room.

If you have ever received a bill for an emergency room visit, you know how brutal they can be. Because of the nature of emergency medical care, emergency room care is among the most expensive you can receive.

Not only that, but if you have health insurance you have likely also been hammered on your health insurance reimbursement for one reason or another, such as lack of pre-authorization for medical care, medical care not being “medically necessary,” or use of non-network healthcare providers.

Sadly, a 2004 Rand Corp. study found that one out of every six emergency room visit claims was denied by two large HMOs in California, and in Pennsylvania, insurance officials have found that 631 consumers had their emergency claims improperly denied between 2001 and 2007 by HealthAmerica, a Pennsylvania-based insurer.

In particular, health insurance companies are often loathe to reimburse emergency room care because it often occurs at non-network hospitals. Patients in the middle of a life-threatening medical emergency are just not likely to travel to a hospital an hour away, just because it happens to be the hospital in their health insurance network, and certainly, we would never advocate it.

Now, healthcare reform offer patients new protections regarding their health insurance when they go the emergency room. Here are some of the highlights:

Out-of-Network Emergency Room Care Must be Reimbursed at the Same Rate as In-Network Care. Whether you are treated at an in-network emergency room or one that is out-of-network, your health insurance company will be required to cover your medical care at the same rate.

Pre-Authorizations Prohibited for Emergency Room Care. If you need emergency room care, health insurance companies will be barred from requiring you to get a pre-authorization before you receive care.

“Prudent Layperson Rules” Required. If you prudently believe that you need emergency medical care, your health insurance will be required to cover it, even if it later turns out not to be the case. For example, if you go to the emergency room with chest pains, believing it to be a heart attack, and it later turns out to be indigestion, your health insurance will still be required to cover your care because the treatment made sense at the time.

These new healthcare reform rules will apply to new health insurance policies issued after September 23rd. In addition to helping patient avoid medical bankruptcy, part of the impetus for the new rules is the hope that people will seek timely medical care instead of delaying their care for financial reasons.

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For more on related topics, visit MyHealthCafe.com:

Emergency! Emergency! Emergency Room Medical Care For the Uninsured

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1. Emergency! Emergency! Emergency Room Medical Care for the Uninsured
2. Emergency! Emergency! How to be Smart About Using the Emergency Room
3. Healthcare Reform: Going Without Health Insurance
4. Healthcare Reform: Where Do Immigrants Stand Under Healthcare Reform?
5. Healthcare Reform: How Will It Really Affect Hospitals and Doctors