1.Should I go to an urgent care clinic instead?
An urgent care clinic might be the place to go if you need immediate attention for a non-life threatening injury or illness, and you can't get in to see your primary care doctor. You fell off your bike and need stitches, for instance, or you think you have strep throat. The clinics see patients on a walk-in basis and have extended hours.
Urgent care is far less expensive than the hospital, so you likely will pay less out of pocket if you go there than the ER, says Carol Taylor, a member of the National Legislative Council for the National Association of Health Underwriters.
However, sometimes the emergency room is the only place to go if the doctor's office and urgent care clinics are closed or if you require certain tests. Urgent care clinics don't have all the equipment that hospital emergency rooms have, such as CT scanners, and they're not equipped to deal with major trauma.
In recent years, the notion that emergency rooms are overused has been overstated, says Dr. Bret Nicks, associate professor of emergency medicine at Wake Forest University School of Medicine and a spokesperson for the American College of Emergency Physicians. Studies that claim emergency room misuse are based on the patients' discharge information, he says, not on the symptoms and the logical assumptions patients were making when they went to the hospital. Aperson might go to the emergency room with chest pains, thinking they are having a heart attack, for instance, but find out it was indigestion and stress.
"Emergency medicine should really be seen as what we call acute care medicine," Nicks says.
Not sure which is the best option? Some health insurance plans provide a hotline you can talk to a nurse about your symptoms and get some guidance on the best course of action.
2. Is the hospital in my health insurance plan's network?
Under the Affordable Care Act, health insurance plans must provide the same emergency care benefits, regardless of whether the patient goes to a hospital in or out of the network. Insurers can't charge a higher copayment or coinsurance, or require you to get prior approval if you get emergency care at an out-of-network hospital.
However, you should be aware of the possibility of "balance billing" if you go to an out-of-network facility. Balance billing occurs when medical providers bill you for the difference between what a health plan pays and what the providers charge.
Hospitals that are in the network have contracts with your health insurance company to accept a certain amount of payment for services.
An out-of-network hospital might charge more than what your health plan considers "reasonable and customary." If the health plan pays less than what the hospital charges, the hospital "is not going to consider it payment in full," Taylor says. It will send a bill for the balance to you.
3. Are the doctors and other staff in my plan's network?
You may get multiple bills from one emergency room trip -- one from the hospital, one from the emergency room physicians, another from a lab and so on.
Even if the hospital is in your health plan network, the emergency physicians and others who provide care there, such as radiologists and anesthesiologists, might not be.
The doctors might not have contracts with your health plan and might charge more than the plan is willing to pay, Taylor says. So you could encounter balance billing with ER doctors or other medical professionals, even if you don't encounter it with the in-network hospital.
Restrictions on balance billing vary by state. In some states, carriers will pay as billed by the doctors if the patient goes to a hospital in the network, Taylor says.
4. How long are the wait times?
According to the CDC, about half of people who visit the ER are seen within 15 minutes, but it's important to understand that how fast you'll be seen is directly related to the potential seriousness of your condition. If you arrive with chest pains, you'll likely be seen faster than if you arrive needing stitches. Hospitals triage patients based on how life-threatening the condition is, so if you're unlikely to die, you'll probably wait longer.
Wait times also vary by the day of the week and time of day.
Many hospitals post their average emergency wait times online. Pro Publica features an "ER Wait Watcher" tool on its website breaks down the information by state and then by hospitals within each state.
Meanwhile, if you don't have a life-threatening injury or illness, some emergency departments let you register online before you go to the hospital. You can virtually check in and spend the estimated wait time at home instead of the hospital. Some urgent care clinics also provide this service.
5. What is the hospital's quality rating?
You can compare hospital quality through a variety of sources, including the Medicare.gov website. Click "find a hospital" on the home page, enter your location, and then click on hospitals to see patient satisfaction survey results and measures on how well the hospital delivers care for a variety of conditions.
"If there's a high incidence of infection, you might not want to go to that E.R.," Taylor says.
The Leapfrog Group provides safety grades for hospitals on its HospitalSafetyScore.org website.
Before an emergency happens
"You never know when an emergency is going to happen," Nicks says. He advises taking these steps before a crisis occurs:
- Understand your health insurance coverage. How much is the copay and coinsurance? Which facilities are in the network?
- If you plan to travel, call the insurance company to find out where you should go on your trip if you have a health emergency.
- If you don't already have a primary care doctor, than establish a relationship with one.
- Keep an "in case of emergency list" in your phone. That list should include your medications, contact information for your primary care doctor and contact information for close family members.
