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What constitues an "emergency" for insurance companies?

Updated: Jan 9

By Martine G. Brousse

"The Medical Bill Whisperer"

Patient Advocate, Certified Mediator

AdvimedPro

 

January 7, 2024

 

Watch the video: 

 

Disclaimer:

always seek medical care, advice and services as needed or recommended by a medical professional. This blog is for informative purposes ONLY, and does not seek to offer any medical advice. You and medical professionals are the only ones suited to make the determination regarding your need to access care, where, how and when.


What constitutes "emergency" for insurance companies?

My experience as a Billing manager turned Patient Advocate has taught me that “emergency” can be defined in 3 ways.

What are they are how do they affect your wallet?

Back to Emergency by order of severity and urgency:

 

A.    Acute and severe: Life of Limb at risk

 

1.     This means that anyone would call 911 and seek immediate help to transport the patient to a facility and to receive care in order to save their life, overall health, organ, limb or system

2.     This would be the highest level of “emergency”, which just about every insurance policy covers without authorization or network requirement.

3.     All efforts are expected to be undertaken until the patient is stable enough to either be discharged or transferred.

4.     Care must be administered by a MD or specialist, and in a facility accredited for that level of urgency, and that can provide the necessary equipment to diagnose and treat the urgency. That usually means an Emergency Room.

5.     Some examples:

·      Heart attack or chest pains

·      Trauma

·      Serious injury

·      Severe allergic reaction including difficulty breathing

·      Intractable pain

·      Stroke

·      Loss of consciousness or seizure

·      Broken bone

·      Mental health crisis

·      Severe bleeding

·      Poisoning and overdose

·      Moderate or severe burns

·      Serious infection or sepsis

·      Pregnancy issue such as bleeding or early labor

6.     While an ambulance is the common way of transport, it is not relevant for insurance companies to determine whether it is an emergency or not.

 

B.    Not acute or severe but serious

 

1.     An illness, injury, symptom or condition that may not be acute or urgent but serious or troublesome enough that a reasonable person would seek care promptly to avoid potential immediate or severe harm.

2.     Care sought for unusual or worsening symptoms, and requiring examination, interpretation and intervention within a short period of time but not on-the-spot

3.     Circumstances that do not usually require calling 911 or ambulance transport

4.     Level of care by MD or specialist may not be required

5.     Special facility or equipment may not be required

6.     Services are usually provided by local Urgent Care Centers

7.     Some examples:

·      Allergic reaction (without breathing issues)

·      Intense pain

·      Infection

·      superficial wound

·      chronic disease episode

·      fever

·      mild asthma attack

·      bronchitis, COVID, flu

·      minor injury

 

C.     Benign, non-acute, non-urgent

1.     This is the care that is less likely to immediately threaten one’s health or life, but that still requires medical attention in the short term

2.     Care does not require a MD or specialist

3.     Care does not require a facility or specialized equipment

4.     Care usually performed at Urgent Care clinics, Minute clinics, through Teledoc or at a Dr’s office

5.     Examples:

·      Minor infections (eye, ear, skin)

·      Flu, cold, COVID

·      Minor wounds

·      Low grade pain

·      STDs

·      Minor side effects or allergic reactions

·      Digestive issues

·      Sprains

·      Common childhood illnesses

 

D.    Your wallet

 

1.     Life of Limb at risk

·      Widely accepted as “emergency” under all plans

·      Paid at the highest rate, regardless of network status of the provider and/or facility

·      Subject to special State and Federal No Balance-bill mandates

·      No requirement for a special authorization

 

2.     Not acute or severe but serious

·      Widely accepted as “emergency” under all plans as long as severity and urgency are justified and documented …

·      … and if involved MD and/or Urgent Care justify “ER” coding

·      Paid at the highest rate, regardless of network status of the provider and/or facility

·      Subject to special State and Federal No Balance-bill mandates

·      No requirement for a special authorization

 

3.     Benign, non-acute, non-urgent

·      Not considered ER if severity and urgency are incompatible with the place of service or license of professional

·      If RN, PA or NP renders the service, emergency status may not be accepted

·      Rate of pay would then be based on network status of the provider

·      Services would NOT be subject to special State and Federal No Balance-bill mandates

·      May be denied for payment altogether, if insurance deems that a lower level of care should have been used (i.e. you went to the hospital ER for a benign UTI, for heartburn but not a heart attack or you used Urgent care for something better handled by PCP during business hours or by the insurance nursing line)

 

There are avenues to force an insurance to pay highest rates for something that was deemed an emergency at the time of admit, but turned out not to be one, or other denial reasons. To be explored in a separate blog.

 


What constitutes an emergency for insurance companies
What constitutes an emergency for insurance companies

 

Martine Brousse was a long-time Billing Manager for Physicians before switching to the side of patients in 2013. The move has allowed her to apply her deep expertise and vast experience of the intricacies of resolving all types of medical bill and claim payment issues in ways that directly and positively impact her clientsʻ finances.

 

(424) 999 4705 - F (424) 226 1330

@martine brousse 2024 @ the medical bill whisperer 2024

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