Studies suggest that about one-third of ER visits are for non-emergency matters. An old guideline defines an emergency as a medical condition with such severe symptoms that a person with average knowledge of health and medicine could reasonably believe their health would be in danger without immediate medical attention.
Limiting ER usage transfers the burden to consumers to self-diagnose. If the coverage is denied, then the patient can appeal. This policy results in claim denials, up to 1,000 ER denials by one carrier.
Prepare: What to Bring to the ER
* Complete health insurance information. Bringing your insurance card provides the necessary data. Note, if your policy denied the service due to a missing preauthorization, appeal the decision especially if the service was due to a true emergency situation.
* Medication and allergy lists. Bring multiple copies as your family member will have several contact points during the visit.
* Medications that will be needed during the first few hours.
How to Fight Claim Denials
* Really know the times to use the ER. While there are no rules, an ER visit is justified if someone is unconscious, can't breathe, bleeding heavily, has a broken bone, is fainting, or feels unexplained dizziness. If you're uncertain, most insurers staff a 24-hour nurse line to call to receive guidance.
* Know your coverage. Most policies offer general guidelines on emergencies under the emergency service benefits of the policy.
* Appeal. If you received a claim denial letter, it will contain the deadline for submitting an appeal. There is a resource called Your Guide to the Appeals Process published by the Patient Advocate's Foundation that includes sample appeal letters and facts about appealing.
* Complain to your state insurance commissioner. The Consumer's Union has an End Surprise Medical Bills site that lists where to file complaints in each state.
* Negotiate. Start with the Healthcare Bluebook to get an idea on pricing. It's a tool you can use to negotiate a lower price.
Medical Billing Advocates
The majority of medical bills contain errors which are attributed to incorrect insurance decisions, medical billing and or coding issues. Medical advocate professionals work on a contingency on the amount saved or bill at an hourly rate. These professionals are the best at:
* Reading a muddy medical bill
* Identifying billing errors
* Negotiating for you
Some of the errors detected by these pros include:
* Upcoding to a more complicated code which costs more
* Unauthorized treatments
* Medical errors including decimal point errors
* Services the patient did not receive
* Canceled work
If you're at a loss about a healthcare bill that appears too high or that you cannot understand, contact your medical provider, insurance plan administrator or a medical bill advocate for a second opinion.