Avoid problems after an emergency

A medical emergency is no time to dwell on insurance coverage. For any threat to life, limb or bodily function, such as severe physical trauma, sudden chest pain, serious blood loss, a possible broken bone, a sudden inability to use a limb, loss of vision, or an "explosive" headache, you need to act fast.

"If you believe you have a true emergency, you should go to the nearest emergency room," says Susan Pisano, Vice President of Communications at America's Health Insurance Plans, a national association representing nearly 1,300 health insurance companies. "If you are insured and you believe it was a true emergency, you can expect coverage," says Pisano. Once you've been admitted and are in a condition to do so, you can call your insurance company and learn the rules of your plan and decide what to do next.

No one likes to think about a medical emergency. But in the event that you have to make a quick decision to go to the emergency room or you wake up in a hospital after an emergency, there's some basic information you should learn in advance about your insurance plan's emergency coverage.

• Verify which local hospitals are in your health plan's network. (In a true emergency it shouldn't be a concern, but for other less urgent emergency treatments you should know where to go.)
• Understand your options and your plan's procedures for after hours non-emergency treatments and urgent care.
• Determine the extent of your emergency coverage. If you're traveling out of state or out of the country, there may be different rules.
• Know the closest and best emergency departments covered by your plan.
• Know that you are protected by the Emergency Medical Treatment and Active Labor Act (EMTALA), which entitles every person who comes to the emergency department to be evaluated and treated for an emergency regardless of their insurance coverage or ability to pay.
• Find out the limits of your emergency care coverage. You may find yourself at a hospital that doesn't participate in your plan. You are likely to be covered for most emergency related services and treatments; however once your condition is stabilized your insurance company may want you to transfer you to an in-network hospital.

It's what you or an advocate does after you arrive at the emergency department that's most important, especially if you're at an out-of-network hospital.

Once your condition is stabilized, the issue of whether you're at an out-of-network facility and whether you continue your treatment there will become important. "A patient should make it known if they're out of network," says Dennis Beck, MD, a nationally recognized expert in emergency medicine reimbursement. "If it's not going to be a risk to change hospitals, then tell them you prefer to be transferred and they can evaluate the risk," says Beck.

"Many people have a knee-jerk negative reaction to being moved at all, but often you're better off being cared for by doctors who know you and have your medical records available," says Maura Carley, a health-insurance expert and advocate with Healthcare Navigation. But moving isn't always an option if it puts you at risk for complications.

Occasionally, what you thought was an emergency turns out to be a less serious condition, but the visit should be billed as an emergency. For example, if you thought you were having a heart attack and went to the nearest emergency room only to learn it was a bad case of indigestion, your insurance company shouldn't bill you for a non-emergency visit. If they do, it's probably because the hospital coded the bill incorrectly, but you can appeal the charge.