Emergency Room or Urgent Care? Choosing the Right One and Avoiding Costly Fees

Starting August 6, 2018, some Texas Blue Cross Build Shield (BCBS) insurance policyholders could receive a surprise ER bill for services they thought were covered. America’s ER laid out the basics of the upcoming policy changes in this article. But these policy changes beg the question, when should patients go to an emergency room vs urgent care?

Emergency Room vs Urgent Care

Emergency, Urgent– they seem to be the same thing, right? Not quite, and there are important differences between emergency room facilities and urgent care facilities; differences in the level of care and the cost.

Urgent Care

Urgent care facilities are for an injury or condition that is too urgent to wait for a doctor’s appointment but not serious enough to visit an emergency room.

Urgent care is a good option for simple and uncomplicated conditions that show up suddenly, such as pink eye and poison ivy.

These are the conditions that Blue Cross Blue Shield of Texas lists as non-emergencies:

  • Colds, sore throat and flu symptoms
  • Ear or sinus pain
  • Rashes
  • Cuts that don’t need stitches
  • Constipation
  • Tolerable pain

Emergency Rooms

An emergency room, whether stand-alone or as part of a hospital, is for serious, potentially life-threatening emergencies such as breathing problems, extreme pain, heavy bleeding and broken bones. However, medical conditions are not always what they seem. While on the surface, neck pain and a fever might be something as basic as a cold, it could be something much worse, like the early stages of meningitis. Only through focused diagnostic testing and a careful physical examination by a doctor can these conditions be ruled out. Injury and illness do not always follow what we’ve heard or read online and sometimes those seemingly basic symptoms are just the beginning of a potentially life threatening condition.

These are the conditions that Blue Cross Blue Shield of Texas lists as emergencies:

  • Heart problems
  • Breathing problems
  • Heavy bleeding
  • Broken bones
  • Severe pain

Is it an emergency?

Time is precious during a crisis. It’s best to have a plan that all family members and caretakers are familiar with, and to have important information, like insurance cards and medication information, easily accessible. If you think something is an emergency or could become an emergency, go to the emergency room or call 911 immediately.

It is notoriously difficult to determine what is an emergency though– even for knowledgeable health professionals. According to a 2017 article by the Los Angeles Times, “research, published last year in the Journal of the American Medical Assn., found that ER doctors and triage nurses often were unable to distinguish urgent from non-urgent visits without examining the patient. Six of the 10 top reasons for unnecessary visits, including back, abdominal and chest pain and sore throats and headaches, were also among the top 10 symptoms of real emergencies.”

Blue Cross’ new policy places the burden of medical diagnosis on patients, requiring patients to discern if something is an emergency, even though a regular layperson is not qualified and trained to do. Blue Cross says it will make decisions on whether an ER visit was actually an emergency based on the patient’s intent so when speaking to your doctor, be sure to describe precisely your concerns about your symptoms. Because “intent” is what BCBS claims they will base their decision to pay or not for your care, the more the doctor can document, the better chances are your bills will be covered if you are treated in an emergency room.

For instance, if a patient has sudden, severe abdominal pain and they go to the ER, Blue Cross says it would probably cover that claim because the patient could have a life-threatening condition. But, if a patient went to the ER for a minor ailment because it was convenient, Blue Cross says it probably wouldn’t cover the claim.

Grey areas

How do you know if abdominal pain is severe enough for an ER visit? Is an unusual headache just a headache, or a symptom of something serious like meningitis or a hemorrhage? Is your child’s wrist sprained or broken? Is your cough bronchitis or pneumonia?

Grey areas abound when it comes to health– that’s why people seek out help. But no one wants that help to cost them exorbitant amounts.

Freestanding emergency rooms became common in Texas around 2012. The model can make care more accessible to patients and sometimes cheaper, but sometimes it’s easy to confuse a freestanding emergency room with an urgent care center.

To avoid going to the wrong type of care center, research emergency facilities in your area ahead of time. It’s best to know the location of emergency rooms and urgent care centers before an emergency happens. For non-emergencies, head to an urgent care facility that is in-network. For emergencies, go to the closest emergency room. If possible, seek out facilities with both an emergency room and an urgent care center.

America’s ER is just such a place. With both an emergency room and an urgent care center, during your visit, an ER board certified physician determines if the Emergency Room or Urgent Care Center is the most appropriate department for treatment. However, their assessment does not protect you from denied insurance claims. America’s ER provides the correct level of care for all sorts of conditions. But, if you have an HMO insurance policy with Blue Cross Blue Shield of Texas, you should check their information about in-network and out-of-network emergency room costs.

America’s ER doesn’t want the grey areas of health insurance to cost you and get in the way of the most important thing: your health.

Insurance is confusing but don’t feel overwhelmed. We’ve broken down all the important things you need to know.