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November 5, 2012

When should you go to the emergency room?

By Chris Kissell, InsWeb.com

It’s Sunday evening and you begin to feel mild chest pains. Or perhaps you splash boiling water on your hand and worry it may turn into a blistering burn.

Should you take your medical concerns to the nearest emergency room?

If the condition is a serious medical emergency – or even if you’re unsure, but think it might be – heading to the nearest ER probably is in order, says Susan Pisano, a spokeswoman for America’s Health Insurance Plans. Pisano’s group represents health insurers around the country.

Pisano’s definition for when people should use ER services is simple: “They should use the emergency room when they believe they have a serious threat to their life or health.”

The American College of Emergency Physicians says the following symptoms could indicate a situation serious enough to require emergency care:

• Difficulty breathing or shortness of breath.
• Chest or upper abdominal pain or pressure.
• Fainting, sudden dizziness or weakness.
• Vision changes.
• Confusion or changes in mental state.
• Sudden or severe pain.
• Uncontrolled bleeding.
• Severe or persistent vomiting or diarrhea.
• Coughing up or vomiting blood.
• Suicidal feelings.
• Difficulty speaking.
• Shortness of breath.
• Unusual abdominal pain.

Some extra costs

Some people hesitate to use the ER, worrying that out-of-pocket costs may be higher than fees associated with a standard visit to a physician’s office. In fact, that’s likely to be the case, although the extra out-of-pocket costs vary from health insurer to health insurer.

ER services are more expensive for two reasons, Pisano says. “Emergency rooms need to be staffed 24 hours a day,” she says, “and they need to have all the equipment and technology available to them.”

On the other hand, some concerns about extra costs are unwarranted.

Thanks to the federal health care reform law, many people don’t have to worry about whether an ER is in their health plan’s network. (An in-network provider negotiates lower rates with a health insurer and charges those rates to the insurer’s policyholders.)

Health care reform prohibits new insurance plans from charging higher co-pays or co-insurance (the percentage of care costs for which a patient is on the hook) for emergency services that are out of network. Some older plans don’t have to comply with this rule, so check with your insurer to be sure.

Another common worry about ER services also is unfounded. “You do not need prior approval from your health insurance before going to the emergency room,” Pisano says.

Most states already have laws that prohibit health insurance plans from requiring you to get “prior authorization” before seeking emergency services. Health care reform has added a federal restriction of that practice.

Less serious illness

Of course, the ER should not be used to treat basic illness. “We certainly do not want emergency rooms to be used for routine care,” Pisano says.

In other words, don’t head to the ER if you have a buildup of ear wax or if you have the occasional mild ache in your left knee after a morning run. Tammy Arnold, a spokeswoman for health insurance company Aetna, says that if you determine your situation doesn’t require immediate care, it’s probably best to avoid the ER.

Here are two good alternatives to ER care.

• Urgent care centers.

These centers provide medical treatment for ailments and injuries that require prompt attention, but which do not rise to the level of an emergency. Small cuts or burns, ear infections or minor sports-related injuries such as sprains would be good candidates for a visit to an urgent care center. An urgent center is a particularly good choice if you need this type of care when your regular physician’s office is closed.

“Your out-of-pocket costs will likely be higher when using ER services,” Arnold says. “Urgent care centers often offer quicker, more affordable care.”

• Retail health clinics.

Pharmacies such as CVS and Walgreens and retailers like Target and Walmart now offer care at many locations for minor ailments – such as ear infections and routine allergy flare-ups.

Nurse practitioners and physician assistants typically work at these sites, which offer treatment that can be up to five times cheaper than ER care, Arnold says.

Both urgent care centers and retail health clinics provide care without the need to schedule an appointment. If you’re unsure whether these types of care are covered by your plan – or if you simply aren’t certain which type of treatment is best for you – check with your health insurance provider.

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