When Emergency Strikes, Will Your Health Care Costs Be Covered?

You may not think about what your emergency health care covers until it's too lateMost Americans don't think about emergency care coverage until they actually need emergency care.

After Randy Gardner was shot at the recent mass shooting at a Safeway store in Tucson, Ariz., he immediately thought, "What is this going to cost me?" according to an article in The New York Times. Of the people injured that day, Gardner was one of the 5% who had no health insurance.

The costs of an unexpected injury can lead to a financial disaster for the uninsured, a quagmire of bureaucracy and uncovered costs for the insured, and stacks of bills for both. According to the most recent statistics available from the Centers for Disease Control and Prevention, in 2007, there were about 117 million emergency department visits in the U.S., 2% of which resulted in admission to an observation unit.The Emergency Medical Treatment and Active Labor Act, part of the COBRA health reform passed by the U.S. Congress in 1986, stipulates that any hospital receiving federal funds cannot refuse care to anyone who seeks care at an emergency room, regardless of insurance status. But that doesn't mean you won't be responsible for the final bill.

Dr. Jesse Pines, a spokesman for the American College of Emergency Physicians and director of the Center for Health Care Quality at George Washington School of Public Health and Health Services, said his hospital never turns away patients. "Ninety-eight percent of U.S. hospitals fall under the EMTALA requirement," Dr. Pines said. "Insurance status doesn't play into the amount or level of care emergency departments provide. But people who are uninsured still get billed."

If you're one of the 50 million Americans not covered by a private plan or a public one, such as Medicare or Medicaid, Dr. Pines advises, "Don't ignore the bill. It will be sent to collection and can have an impact on your credit. The best thing to do is to call the hospital and work out a payment plan." He added that many (but not all) hospitals will reduce the balance for people who cannot pay the full amount.

Talk to someone in the hospital's social work office (most have one) to see if you qualify for Medicare or Medicaid, and what the process is for getting charges reduced or dropped altogether. Associations such as the Patient Advocate Foundation have publications that list state-by-state free programs and other resources.

Even people who are insured can have a hard time getting their emergency costs covered in full (remember the woman in Michael Moore's documentary Sicko who was billed for an ambulance ride because she didn't get approval in advance for the service, even though she was unconscious due to a car accident?). If you're insured and have to go to an emergency room, you or someone with you should call your insurance company. Ask what's covered if you're admitted and if you're not admitted for further treatment, and if the copay is the amount indicated on your insurance card. You may also want to check that the hospital you're going to is in the network specified by your coverage -- some insurance companies cover initial emergency room visits anywhere, but may expect patients to move to an in-network hospital when possible.

When an insurance company refuses payment on any or all services, there are steps you can take. Previously, patients' right to appeal varied by state and insurance company, but under the Obama health care plan, the appeal process is more uniform and all appeals are subject to an external review board in every state.

The AARP recommends people disputing denied claims keep detailed records of the date and time of each call to the insurer, who you spoke with and what was said. Be persistent -- just because your claim has been denied more than once doesn't mean your appeal won't reverse the decision. And be aware that all health insurance companies have deadlines for filing appeals, so determine what that date is and don't delay.

The victims in the Tucson shooting probably won't have to worry about their bills. Safeway formed a victims' fund starting with an initial $100,000 that will be added to by in-store contributions from customers and community members. Several other fundraisers have sprouted in Arizona and around the rest of the country.

Such high-profile calamities often draw enough attention that both insurance companies and donors cover medical costs for victims. This "VIP syndrome" type of care and coverage is not uncommon, according to Dr. Pines. "Physicians often act differently around celebrity care," he said.

If you're insured and costs aren't covered, don't accept what your insurance company is telling you about your coverage. Find out your state's appeal process and look for other resources to help you get your claims settled. If you're uninsured, either hope you're famous enough or infamously enough injured to have your costs covered anyway.
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