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Non-emergency visits to the ER might not be covered by insurance - Medically Speaking, Volume Two, Number Seven, 01/22/15

When it comes to surprises, most people would say they love surprise parties, gifts, money and other forms of unexpected, favorable news. However, the same people would say they don't like unexpected bad news.

In that same vein, officials at Utah Navajo Health System, Inc., and Blue Mountain Hospital are not fond of doling out bad news either, of any kind, to their patients. This includes unfavorable surprises, regarding all types of information, including bills for services insurance companies won't cover. That's why UNHS is making a serious effort to educate patients to the pros and cons of going to Blue Mountain Hospital Emergency Room for medical reasons that are not considered emergencies, or medically necessary.

UNHS CEO Michael Jensen said people are free to go to the Emergency Room whenever they want to, but the problem lies in the fact that unless their insurance, including HIS funding through Purchased/ Referred Care, covers those trips to the ER, the visit might not be free.

"As a 638 contractor we get monies from the federal government to treat Native American patients, and we want to treat as many people as we can with that money, "Jensen explained. "We want our patients to know that when people go to the ER, hopefully they are going when they need it most and when it would qualify for Purchased/Referred Care. If they show up at the ER and their visit doesn't qualify, then we can't pay for it. We don't want that to happen because it's a bad situation for them. And so, we just want to get information out to the community about what does qualify, and then people can make their own decision at that point. They will be billed by the ER if we can't pay for it… if it doesn't qualify."

The term Purchased/Referred Care (PRC) is the new name for what used to be called 'Contract Health,' according to Evans Hollie, a PRC Coordinator with UNHS. Hollie said that if a patient is experiencing any medical condition for which immediate medical attention is necessary to prevent the death, or serious impairment of the health of the individual it would qualify as an ER visit under PRC guidelines.

"Say you're riding a bike and you fall off and break your arm. For sure that is medically necessary and you can go to the ER. But if you're having a cold or maybe your temperature is a little more than normal, then we would encourage you to seek over-the-counter medication or whatever medication you have first, than to initially go to the ER," Hollie said.

Nick Fox, Clinical Manager for the UNHS Blanding Family Practice Community Health Center, explained the ER criteria this way, "If a patient comes in and their pain ratings are really high, their fever is really high, they're having EKG issues and problems, and their lab values are off the charts, that becomes an urgent visit and IHS will usually cover that type of visit. If it's deemed medically necessary they will usually cover that. Any type of insurance will be the same way. If you go in and there's no fever, your pain rating is tolerable pain, and there are no lab values showing out of whack, then IHS, or any other insurance, to be honest with you, Medicare, Medicaid, any of them, would not deem that medically necessary. Then it falls back onto the patient."

Laurie Okkema also works with the Purchased/Referred Care Team at UNHS. She explained that in many cases patients with nonemergency conditions could make an appointment to see their Primary Care physician at a UNHS Community Health Center the same day, or the following day. Where available, they could also visit an IHS Clinic if necessary, rather than visit the ER.

"What we see are people visiting the Emergency Room for needs that could be taken care of at the primary Care Provider's office. Now certainly, if there's a life-threatening thing, any threat to life and limb, of course, emergencies belong in the emergency department. But if the clinic is open they really need to see their Primary Care Provider for things that can wait. If you have a cold, having an appointment for the next day would be fine," Okkema said. "The biggest advantage to patients for waiting, if possible, is expense. Expense, potentially to the patient, depending upon what their insurance coverage is. It may not be covered if they go to the emergency room for a nonemergency need. That is the biggest problem."

Jensen, Fox, Okkema and Hollie all agree that during clinic hours, patients without emergency needs should see a Primary Care Provider at one of the UNHS clinics, or an IHS clinic. However, some patients are concerned about contacting providers when UNHS clinics are closed. In this case, Fox explained, patients can call the UNHS clinic of their choice and either leave a message for the front desk to hear the next morning, or they can be transferred to a nurse in the Blue Mountain Hospital Emergency Room. This is part of the Patient Centered Medical Home program.

"If they actually hit the number to go to a nurse that will transfer them to the Blue Mountain Hospital Emergency Room. The nurse there does a Telephone Triage," Fox said. "Depending on what that nurse hears during that assessment, she will recommend whether the patient needs to be seen at the ER or if they can schedule an appointment for the next day. They can say, 'yes you can come to the ER tonight' or say 'you're right on the borderline. You can either wait until tomorrow and we can get you an appointment, or we'll leave it up to your choice, you can come in and be seen or you can come in tomorrow.' It all depends on what the symptoms are."

Fox said, if a patient calls in after hours and the ER nurse determines that the patient needs to go to the Emergency Room, they have a choice of where to go. Even the nurse in the ER is not going to say, 'you have to come to the ER.' They will say, 'In my opinion and from what I'm hearing, it would be best if you came to the ER this evening.' He said patients can also request an appointment over the phone. If that happens, the ER nurse can send an email to the front desk at the clinic, where the patient choses to go, and let the front desk workers know to call this patient and make an appointment for them that day.

Hollie said thatAll Eligible Navajo patients, who reside in the UNHS service area, and are registered with UNHS, and meet all Purchased/Referred Care Eligibility Criteria qualify for the Purchased/Referred Care program. He said the program also helps Navajo students from Arizona, and other parts of the Navajo Reservation, who attend college in San Juan County, may qualify and receive assistance from their home service area Purchased/Referred Care Program. The program helps facilitate medical assistance and other benefits for students who are IHS patients.

"We do our best to try and educate the patients to let them know what we do cover and what we don't cover," Hollie said. "At the same time, if they do go to the ER and it's something we can't cover, we'll still try to assist them with working with an eligibility worker to help them apply for alternate resources that would cover the visit as well. Either through the State or the County. Or if it's crime related then we'll have them apply with the State of Utah for the Crime Victims Reparations Fund. The county also has their own program for that."

"Let's be perfectly clear," Jensen stressed. "Anybody can go to the ER any time they want. If they want to be seen, and it doesn't meet our criteria, they can still be seen but they're just going to have to pay for it. We've talked to Blue Mountain Hospital staff, about what they're supposed to do. They're nurses will do an assessment. If they think it may not be medically necessary or emergent, Blue Mountain Hospital doesn't want to get stiffed with the bill either, so they will say, 'we'll see you, but we're probably going to bill you as a patient for this.'"

"One of the problems is that Blue Mountain Hospital is just too good. It's so accessible and they can get people in (snap fingers) like that," Okkema added. "At least back in Chicago, the thought of having to go to an emergency room, I mean oh my gosh! Things are better nowadays, but back in the day people were waiting three or four hours to be seen, or longer. That was a last resort. It wasn't encouraged."

Okkema concluded by noting that people go to the ER and they're asked, 'how long has this been going on?' They answer, several weeks or several days. 'So what brought you to the ER now?'

"If they want to go to the ER they can go, but we just don't want anybody to be surprised. If that's what they want to do, that's fine. But they might have to pay for it," she said.

Unexpected bills for nonemergency ER visits, not covered by an insurance company, are among those bad surprises no one wants to receive. UNHS patients are encouraged to educate themselves about what types of medical conditions qualify as valid Emergency Room visits and what conditions don't qualify. Talk to your provider, or to a Purchased/ Referred Care advocate at one of our UNHS Clinics to learn more.

Emergency Room visits are sometimes a necessary option if there is an extreme medical emergency. As mentioned above, those situations are usually covered through your insurance. However, in cases of nonemergency situations, while patients are entitled to visit the ER, it is often best to consult your Primary Care Provider, or call the clinic, before visiting the ER. UNHS and BMH are here to meet the healthcare needs of our patients, but we don't want an unqualified ER visit, and the bill that follows, to become an unwanted surprise for them.

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