Making assumptions about your medical insurance coverage can be a very costly exercise. Many people incorrectly assume that if they go to the emergency room, their health insurance will cover the cost of any medical bills. However, insured patients are often surprised when they receive bills, especially when there is more than one bill for emergency room care — often amounting to thousands of dollars. When the visit turns out to have been for a minor illness, those bills become even more devastating.

Emergency rooms are one of the most expensive places to receive medical treatment, even with insurance. While coverage can vary widely depending on your policy, most insurers will only cover emergency room treatment in the event of a true emergency. However, even in urgent situations, patients can end up being held accountable for substantial out-of-pocket costs that they did not expect. It’s critical to be aware of your financial responsibility for any medical bills you might receive before you face an emergency.

ER Costs: Copay or Deductible?

Every insurance company handles the fees for emergency room care differently — some apply copays to these visits while others apply the costs to your deductible. When copays are applied, they usually are higher than those you would pay to your primary care physician. In the cases where all charges are applied to your deductible, you need to fully satisfy that deductible before your insurance will start to pay the costs for that care. It’s a good idea to carefully review your policy in advance of care to determine how your insurance company handles such cases and how they are covered.

Meeting Your Deductible

A deductible is a specified amount that you must pay annually for your medical care before your health insurance pays any of your medical expenses. Importantly, if you obtain emergency treatment at the beginning of your policy year, those bills will likely go toward meeting your deductible. For example, if your deductible is $1,000, you will need to pay this amount out-of-pocket before your policy will kick in to cover any health care costs, even in the event of an emergency. The higher your deductible, the more you could end up paying out-of-pocket.

It’s essential to understand that your deductible is based on the amount allowed by the insurance company, not the amount of the total charges. This means that if you haven’t met your deductible and incurred $1,000 in emergency room bills — but only $400 were deemed allowable expenses — you would be required to pay $400 out-of-pocket, which would go toward your deductible. Any responsibility for the remaining amount would be determined by whether the providers were out-of-network or not.

Out-of-Network Costs

If you go to a hospital that doesn’t participate in your insurance plan, it is considered “out-of-network.” Many plans will cover out-of-network costs in the event of an actual emergency at what the insurance company considers the allowed amount for those charges. This allowed amount can be determined by each insurer in one of any number of ways, but in most cases, it will be less than what the out-of-network provider has billed you. Once this allowed amount is determined, any in-network deductibles or copays will be applied before your insurance makes a payment to the provider.

Any remaining costs after the allowed amount is applied would be your responsibility to pay. For example, if your $1,000 deductible hadn’t been satisfied and $400 was allowed by your insurance company for out-of-network costs, you would be responsible for paying the $400 toward your deductible — as well as the remaining $600.

It’s important to note that even if you go to the emergency room at a facility within your insurance network, not every doctor who sees you may be part of the network. Since emergency room treatment is typically reserved for life-threatening situations, you could be seen by a number of specialists who will conduct diagnostic testing or take X-rays to rule out any particular conditions. Not only will you receive a bill from the hospital, but each individual provider will also send one. If any of the providers you see are out-of-network, you may incur the costs of the entire bill, or at least a substantial portion of it, depending on your policy.

Since out-of-network costs can be extremely high, it’s often best to consider whether you are facing a life-threatening illness and have no other option than the emergency room. If feasible under the circumstances, making an appointment with your primary care physician, visiting an urgent care facility, or utilizing telemedicine can be cost-effective alternatives.

Surprise Medical Bill Laws

Some states protect patients from excessive billing by out-of-network providers who work at in-network facilities with surprise medical bill laws. It’s helpful to investigate the protections your state might provide.

How Systemedic Can Help With Your Emergency Room Bill Dispute

If you’ve incurred substantial emergency room bills, an experienced medical bill dispute advocate can help. Systemedic has been advocating for patients who have received excessive medical bills for over three decades and knows how to negotiate even the most complicated bills efficiently and effectively. Offering a fee-based service for those looking to dispute their medical bills, our medical bill dispute advocates are skilled in navigating the insurance maze and will not take “no” for an answer. To get started with resolving your medical bill dispute, contact us for a consultation.