Understanding your Health Insurance

Emergency Room or Urgent Care?

Understand your insurance coverage and be prepared for an emergency!

Carrie de Moor, MD, FACEP
Chief Executive Officer
Code 3 Emergency Partners

Code 3 ER at Carrollton and FASTPASS Urgent Care are excited to become a part of your community. Our goal is to establish a transparent and trusting relationship with our patients. Nowadays, one of the biggest challenges facing patients and providers alike is navigating the complex world of insurance coverage. We understand that the changes in healthcare coverage during the implementation of the Affordable Care Act (Obamacare) can be frustrating and upsetting. We want to help our patients understand their coverage, what that coverage means for their acute unscheduled medical care needs, and also to provide them with alternative payment options to help decrease their out of pocket burden.

Freestanding Emergency Rooms have seen a lot of coverage in the news over the past few years. Unfortunately, negative media attention surrounding these centers has given some patients a misperception of the model. I often hear from friends in the community, “Another ER??? How many of these do we need?” Interestingly, no one seems to comment when they see “another dentist” or “another pediatrician”. Everyone understands primary care, and no one wants to believe that true emergencies occur with high frequency. However, according to the CDC 43% of Americans will experience the need for a visit to an Emergency Room every year. This percentage does not include urgent care visits for minor problems. 87% of those emergency patients are discharged home every year without using hospital services beyond the emergency department. This means that Emergency Physicians are able to handle the overwhelming majority of Emergencies in an Emergency Room alone. The State of Texas began to license Freestanding Emergency Rooms in 2009 and since this time many operators have come into the market, some good, some bad, some corporate, some privately owned.

Code3 Emergency Partners is a group of Emergency Physicians who are residency-trained in the specialty of Emergency Medicine. Code 3 ER is managed by Emergency Physicians with the goal of improving the patient experience and patient outcomes through processes that are designed to provide both quality and efficient care. Our Emergency Room is built to very specific standards that meet the same level of requirements as a hospital based ER. It takes much more to build an Emergency Room than putting up a few walls and putting a sticker on the door that says “ER”. It is what is inside the walls that matter. Inside our walls, you will find Emergency Medicine Residency-Trained Physicians, experienced Emergency Nurses, paramedics, and experienced emergency radiology technicians. You will find imaging equipment, such as CT scans, X-ray, and ultrasound, and a COLA accredited lab. Our ER pharmacy is also licensed by the Texas State Board of Pharmacy. Urgent Care Clinics have much less stringent rules and regulations and are not able to handle high acuity conditions safely like an Emergency Room.

So what constitutes an Emergency? Generally speaking, anything that could be life or limb threatening, including labor, would be defined as an Emergent Condition. Examples of conditions and symptoms that should be evaluated in an Emergency Room (and which can be handled by Code 3 Emergency Physicians) include chest pain, abdominal pain, pelvic pain, acute allergic reactions, shortness of breath, stroke symptoms, fractures and dislocation, severe unrelenting pain, severe headache, syncope (fainting), vaginal bleeding, palpitations, seizures, head injuries, and lacerations (just to name a few!). Urgent Care facilities are often able to handle minor emergencies or urgent needs such as cold symptoms, sore throat, and dental pain, burning with urination, minor sprains/cuts, and medication refills. Code 3 ER at Carrollton is proud to have our affiliated urgent care, FastPass Urgent Care just next door, so you never have to worry about choosing between an Urgent Care and ER. Our Emergency Medicine Residency-Trained Physicians will ensure that you are screened and treated in the appropriate location.

Now, I know you are asking, “How much is emergency care going to cost me”? The reality is that Emergency Care can be expensive because of the number of resources that are needed to care for that emergency, and insurance plans are all very different. Many consumers have noted that premium and deductibles alike have risen substantially in 2016. Healthcare in the United States is moving towards a system where patient responsibility/ out of pocket cost is rising. A few facts to know and understand: 1) In the State of Texas, Emergency Medical Care MUST be covered by your insurance as “In-Network” and apply to your in-Network benefits. 2) Insurance companies are making it more and more difficult for physicians and facilities to negotiate fair payment, which narrows the network for the patients. 3) Your out of pocket responsibility for your healthcare is often broken down into a few categories: Premiums, Copay, Deductible, Co-Insurance, and Out of Pocket Maximum. Here is a quick guide to understanding these terms:

  • Premium: This is the monthly cost that you or your employer pays to the insurance company for you to have access to your plan.
  • Copay: Copays are fixed amounts that are determined by your insurance company depending on the specific plan that you choose. This payment usually varies between primary care offices, specialists, urgent cares, and emergency rooms and does not typically apply to your deductible.
  • Deductible: A deductible is the amount that the patient is responsible for paying before your health insurance plan begins to pay for covered medical expenses annually. Deductibles have risen for most patients in 2016. If you choose a plan with a $5000.00 deductible, you will be responsible for all of your healthcare costs up to $5000.00. Remember, this does not include what you pay in premiums and may not include your copays.
  • Coinsurance: Many often ignore this portion of their insurance coverage when choosing a plan. It is very important. If you have co-insurance as a part of your plan, the insurance company will share the cost of care with you AFTER you have met your deductible. If your plan has a 10% coinsurance, then your insurance company will cover 90% of your covered medical expenses.
  • Maximum Out of Pocket Expense: This is the maximum amount that you will have to pay each year via coinsurance and deductible BEFORE your insurance plan pays 100% of covered medical expenses.

Here is an example of one insurance plan that we have recently seen on the market: Premium- $400/month. Emergency Co-Pay $20.00. Deductible- $4000.00. Co-insurance 50/50. Out of Pocket Maximum: $10,000. So using what we have learned about insurance, what do you think of this plan? If you were to visit the emergency department with abdominal pain and receive CT scans, etc. to find that you had appendicitis, you could potentially end up with a bill to your insurance company that exceeds $5,000. If you had this plan (which you picked because a $20 copay sounds awesome!), you would be responsible to pay your copay of $20, then you would be responsible to pay the $4000.00 deductible and then you would be responsible for 50% of the remaining charges. Your total out of pocket for that visit could be $4520.00. This does not include the $4800/year that you are already paying so that you can take advantage of the 50% coinsurance after your deductible is met. Primary care options may be covered completely in this plan, which is a positive. However, with 43% of Americans needing emergency care each year, this plan does put you at risk for having to pay large amounts out of pocket each year. Your financial situation and what you can afford for premiums on consistent monthly basis will usually determine the plan you choose, but keep these definitions and statistics in mind when choosing a plan.

In an effort to help ease the burden of these high out of pocket costs for individuals with high deductible plans or no insurance coverage, Code 3 ER and Fast Pass Urgent Care offer concierge memberships for as low as $125/month for emergency care and $75/month for urgent care. Levels of membership are based on your projected use of the centers every year. For more information, please visit us at 4228 N. Josey Lane.