Be Prudent with ER Visits

If you unnecessarily visit an ER in lieu of a visit to your Primary Care Physician (PCP) or urgent care facility, coverage may be denied. In that case, a member is responsible for 70% of the allowed amount after the deductible is met.
As SWSCHP has studied this challenge, we’ve concluded that it is important for our members to have a clear understanding of when to actually use an emergency room.

Frequently, we will hear from our members that their primary care physician’s office was closed, which forced them to an ER. But if there is no serious or life-threatening condition, SWSCHP members should visit an urgent care center. Members can also use the telehealth services available to get certain medical care by phone or online, and to help them determine if they need ER care.

How do you know to go to the urgent care center? Here are some examples:

• Your problem is not life threatening or does not have the potential to cause disability, but you are concerned and your doctor’s office is not open.

• You are experiencing a common illness (cold, flu, earache, headache, sore throat, fever, rash) or minor injury (sprain, cut, burn, back pain, eye injury) that does not require an ER.

We know that ‘concern’ is different for each person. But that’s why the doctors at an urgent center are so useful. They can quickly assess your issue and if necessary, will tell you to get to an ER. Isn’t that better than waiting for hours in an emergency room?

That’s why we suggest you find an urgent care facility (preferably one that is open for 24 hours) close to your home. Just check on the Empire BCBS and Aetna websites to ensure that they are in-network.

What Constitutes an Emergency?
So how does one assess whether to immediately go to an emergency room? Injuries like broken bones that result from accidents or concern that one is having heart attack symptoms are two very common ER visits. Often, it is the question of clear urgency that requires a visit to the ER.

The US National Library of Medicine has an excellent checklist that you can review here.

Questions & Answers on Urgent Care Facilities

I thought urgent care facilities were for people who didn’t have insurance?

This is a common misperception. Urgent care facilities are a fast-growth market segment with roughly 8,000 centers in the United States, most of which are owned by large insurance companies, hospital systems, or physician groups. They emerged out of a consumer need to access routine healthcare services in the evenings and on weekends, and now represent a conventional part of the healthcare marketplace.

What are the advantages of urgent care facilities?

At most urgent care centers, wait times are less than 30 minutes for walk-ins, and patients are usually out the door in less than an hour. Most are open seven days a week and have evening hours, and some are even open 24 hours. Visits typically are less expensive than using your primary care physician.

But isn’t it important that I always see my primary care physician for all medical needs, even those that are not urgent?

No. Today, your primary care physician is there to assess the totality of your health and address the conditions that may be chronic or need the intervention of specialists. Routine healthcare for benign issues like seasonal colds or allergies, bee stings, swimmer’s ear, minor cuts or burns, just to name a few, are typically more readily addressed in urgent care facilities. Your records are sent automatically to your primary care physician so that the latter can maintain a complete record of your health.

Why does SWSCHP want us to use urgent care facilities?

Our perspective is that you must make your own healthcare choices that are in the best interest of you and your family. As stewards of the SWSCHP plan, the job of our Executive Director and Executive Committee is to ensure that the plan operates with a high rate of quality in a cost-effective manner. Our internal studies show that urgent care facilities are underutilized by our members, which comes at a higher cost to the plan, and may limit our benefits in subsequent years. Therefore, it is in our members’ interest to encourage greater use of these facilities.

How is this connected to ER care?

It really isn’t. If a member is experiencing an emergency (as defined above), the ER should be used. Our purpose here is to encourage an understanding that ER care – which is the most expensive immediate care provided to members– should strictly be used for emergencies. Use of the ER for events that are not deemed medically necessary will bring substantial cost to an individual member.