I was slicing cheese one Saturday morning when the knife slipped, and as I watched the blade bury itself in my finger, I thought, "I am so going to need stitches." Fortunately, I have an emergency room just three blocks away. But as I struggled to get into my clothes with my hand wrapped in a towel, it occurred to me that maybe my health plan wouldn't consider a cut finger suitably dire to justify a visit to the ER.
If my health plan were to deny the claim, I could be stuck with a big bill, I worried, since emergency room care is a lot more pricey than a visit to the urgent care clinic or my own doctor's office. This is not just idle speculation; I've talked to people to whom this has happened. So I sat down at my computer, logged into my health plan's website, and, pecking with one hand, tried to find some answers. Twenty minutes later, I was still looking (though the bleeding had mostly stopped). What I had found was the address of the nearest in-network urgent care center—an inconvenient hour away on the subway. But I bandaged up my hand, and off I went.
Let me be clear: I'm not at all advocating that people pause to ponder insurance coverage if they're suffering a medical emergency, or even if they're worried they may be. In those situations, get to the hospital right away. But in my case, it was perfectly obvious that while I needed some medical attention, I wasn't going to bleed to death from the tip of my finger. Later, finger mended, I wanted to find out more about coverage for emergency room visits. So I talked with Michael Bishop, a former board member of the American College of Emergency Physicians who's president and CEO of Unity Physician Group in Bloomington, Ind., which staffs hospital ERs and runs urgent care centers in the area. He explained that trauma—anything due to accident or injury—is generally going to be covered under any commercial policy. The sprained ankle, the splinter in your leg, the cut in my finger—they may not be life threatening, but your insurer isn't going to balk at covering them. Fever and severe pain also pretty much automatically qualify as emergency room-worthy medical problems, says Bishop.
There are some situations where people may run into difficulties, however. They include:
- refilling a prescription
- insomnia, unless there's a physical problem that's causing pain
- minor upper respiratory problems or sore throats not accompanied by fever
- bug bites
- minor rashes
- chronic conditions that are no worse than usual at the time of the visit
Even so, all of the above may sometimes be considered emergencies, says Bishop. "Oftentimes it has to do with severity and with how much of a problem it is for that person." In other words, if you've been target practice for a nest of wasps, that's probably an emergency. A bad mosquito bite, not so much. It's estimated that more than half of visits to emergency rooms could be handled at an urgent care center. But none of that matters if you're the one who's sick. Bottom line: If you're worried, go to the ER. Better safe than sorry.