Blog Post

By Carrie De Moor MD, FACEP

CEO, Code 3 Emergency Partners

Should your insurance provider cover your ER visit? It’s a simple question, yet one that increasingly has no easy answer for consumers. This is a question that is being asked more and more every day across Texas. And you’d be surprised by the number of people in the world of Big Insurance who often express reluctance to covering your contractually covered medical care, particularly when it comes to emergency services.

There is no doubt that confusion exists in the marketplace. However, the source of the confusion is grossly misattributed. It is not a coincidence that health insurance company profits are soaring to all-time highs while patients and providers pay an increasingly steep price.

With reckless abandon, some insurance carriers are not abiding by the rules that are meant to protect patients. They are purposely creating doubt in the minds of consumers about whether their emergency care will be covered at certain ER facilities, in order to increase their profits. This practice endangers lives. Through marketing ploys and profit-motivated legislative agendas, insurance carriers are steering patients to higher cost centers where they can reliably make more money on every patient visit.

Patients have been steered away from life-saving care by insurance carriers. It is a dangerous and growing problem. We want only what’s best for patients and their health and wellbeing. Texas families are counting on their elected officials to make the right decision when it comes to protecting their care. We will do all we can to push for these vital patient protections.

In-network versus out-of-network is a red herring when it comes to ER care. According to the law, in a medical emergency, all patients with insurance should have their ER care covered because insurance carriers must apply benefits in an emergency using “in-network” cost sharing provisions.

Yet for that matter, “in-network” does not necessarily mean less expensive than “out-of-network.” This is important for all patients to know.

When consumers enroll in an insurance program, they receive a plan benefit document and a summary benefit document. If their health plan is compliant with the law, that document—which is essentially a contract between the consumer and the carrier—will state in some form that they are covered in an emergency no matter where they seek care under federal and state protections provided by the Prudent Layperson Standard.

No Texan should ever be discouraged from seeking emergency care at the nearest ER. The predatory practice of some insurers to steer patients away from what may be the nearest and best ER option endangers the physician-patient relationship, the independent practice of medicine, decreases competition, hurts small businesses and the communities they serve, and ultimately increases costs for consumers.

This anti-competitive behavior and corporatization of medicine that puts profits before patient care should deeply concern patients, employers, consumers, and legislators.

Texans need to look past the smoke and mirrors charade of the well-funded insurance lobby, and demand that fair and lawful coverage be provided to Texas health insurance policyholders—for their healthcare, including life-saving emergency care.

Dr. Carrie de Moor is the CEO of Code 3 Emergency Partners based in Frisco, TX, and a Board member of the Texas Association of Freestanding Emergency Centers (TAFEC).

NOTE: This blog was adopted from a State of Reform commentary also written by Dr. de Moor.