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Should I Stay or Should I Go? Are your symptoms E.R. worthy? Or are you about to pay a higher copayment or be denied coverage and need to pay for non-emergency services entirely out-of-pocket-for an emergency room visit that could’ve been more effectively, and more economically, served elsewhere? According to the Centers of Disease Control and Prevention, 10 percent of the nation’s more than 110 million emergency room visits in 2002 were classified as “nonurgent.” That means over 11 million people overpaid for their care. If you reasonably believe that you have an emergency, you should go to the nearest medical facility or call 911, when appropriate. An emergency is defined in your Evidence of Coverage as “an unexpected medical condition, including a psychiatric condition, that manifests as acute symptoms of sufficient severity, including severe pain, so that the absence of immediate medical attention could reasonably be expected to result in placing the person’s health in serious jeopardy, serious impairment of bodily functions, or serious dysfunction of any body organ or part.” If you’re an HMO member and you don’t believe you have an emergency, as defined above, contact your Personal Physician who must provide or authorize you all urgent care services. Your Personal Physician has telephone access available 24 hours a day, seven days a week. If you do access the Emergency room of a hospital, you must contact your Personal Physician within 48 hours in order to have the emergency visit authorized. Any follow-up care should be coordinated by your Personal Physician. If you’re a PPO member and you don’t believe you have an emergency, as defined above, you should consider: • Calling your doctor’s office even if it’s after-hours, for advice. |
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