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In the case of a serious accident, illness, or complication stemming from medical treatment, there is no doubt that you should seek emergency medical care. But, in these situations, often, you’ll have to deal with more than just physical and emotional stress.
Today, for over 20% of the 23 million Americans carrying medical debt, unplanned hospital admissions and ER care costs represent the largest share of their outstanding balances.
That’s where understanding your health insurance plan can save you from bankruptcy and long-lasting debt. Here’s all you need to know.
What Are Unplanned Hospital Visits?
The first step to understanding in which emergency situation you’ll be covered by your medical insurance is to learn what unplanned hospital visits are and what costs they entail.
Unplanned hospital admissions include:
- Returning to the hospital after a medical or surgical treatment because of complications
- Emergency room and urgent care visits
When a patient is readmitted to the hospital because of unexpected complications and health pitfalls (including pain management needs), they might face an added risk of healthcare-associated infections, longer recovery times, and financial losses related to taking time off work.
But even more importantly, an unplanned admission can come with a medical bill as steep as $3749 – $12 471.
On the other hand, visiting an emergency room can cost a patient between $2000 and $2200, while a consequent hospital stay can increase these costs by $10,000 per night.
The Expenses Your Insurance Should Cover
There are several factors to consider when buying your insurance policy. And, undoubtedly, both price and coverage limit should be high up on your list.
However, medical emergencies happen when you least expect them, and understanding what your policy will cover can help you deal with the emotional, physical, and financial stress of the moment.
Here are some of the boxes your insurance cover should tick.
Emergency Room Visits
Emergency rooms operate 24\7, throughout the year. That is why they are often the first port of call for patients suspecting a health-threatening condition. However, non-emergency ER care use causes a significant burden on the healthcare system as a whole.
That is why many insurance companies today recommend their clients to check with a local urgent care centre first and won’t cover ER admissions that are not for health- or life-threatening conditions.
At the same time, not all patients have the knowledge or expertise to self-diagnose a health emergency.
So, to avoid claim denials for non-emergency ER use, make sure that your plan covers this eventuality. Or, be clear on your policy’s definition of “emergency”. Be sure to clarify this aspect with your insurer before a medical emergency arises.
Your insurance policy is likely to specify in what facilities and from which health care providers you will be able to receive cover. This is known as “in-network” coverage.
However, in the event of an emergency or unplanned hospital admission, you might not be able to receive care from your regular doctor or at your local hospital.
To prevent a claim denial when accessing out-of-network healthcare, make sure to understand your policy’s coverage and the caps that might have been placed on your health benefits.
It is important to notice that, if your insurance provider does cover out-of-network care, you no longer need to worry about so-called “surprise billing”.
Thanks to the new No Surprises Act, as of January 1st, 2022, patients won’t need to cover the difference between the higher costs of out-of-network providers and the insurance coverage through out-of-pocket expenses.
Copays – or copayments – are fixed, out-of-pocket fees that the patient will need to pay their healthcare providers for their services before these services are performed.
Copays are only applied to services covered by your insurance plan and can range between $10 and $50, depending on the type of service and provider. If you are taking advantage of multiple services, you will pay a copay for each.
But, in the case of a hospital admission via ER, some insurers waive these fees. In this case, all the hospital charges will fall within your deductible. Since health insurance policies can be complex, it is worth looking at how your policy works before you need to use it.
Subsequent Medical Procedures
If you are admitted to the hospital via ER, your insurer will need to cover your medical care costs without prior authorization. However, after your admission, if you require follow-up care, the costs involved might only be covered if you have applied for prior authorization.
While this isn’t always necessary, giving your insurer the chance to review the treatments and prescriptions required can lead to better outcomes.
Understanding Your Insurance Policy Before an Emergency
Over the past years, health insurers have worked to provide higher standards of transparency to their clients. However, most insured patients still face steep medical bills because they fail to understand their policies.
Make sure to speak to your provider before dealing with an emergency to avoid unexpected costs and get the most out of your policy.
The Editorial Team at Healthcare Business Today is made up of skilled healthcare writers and experts, led by our managing editor, Daniel Casciato, who has over 25 years of experience in healthcare writing. Since 1998, we have produced compelling and informative content for numerous publications, establishing ourselves as a trusted resource for health and wellness information. We offer readers access to fresh health, medicine, science, and technology developments and the latest in patient news, emphasizing how these developments affect our lives.