Health Care Systems - What happens when there is an emergency?

The key to handling emergencies smoothly is advance preparation. Whether a person has a raging fever in the middle of the night or falls and breaks an arm, some knowledge in advance will help ease a stressful situation.

It doesn't matter which health insurance plan a person chooses, reading the materials and familiarizing oneself with emergency procedures is a smart idea. Emergency care is often listed in a separate section in the member's handbook and will explain what to do in case of an emergency. Emergency situations often call for quick action. The more a person has done in advance, the more quickly decisions can be made.

Emergency Preparation

The following checklist includes some things to do to prepare for emergencies:

  • Leave a set of clear and simple instructions for emergencies and important telephone numbers near the phone for babysitters and family members.
  • Program the telephone speed dial with 911 and the health plan's advice line and urgent care line numbers.
  • Check out the health plan's policies for out of town or out of service area emergency care
  • Check into how to notify the health care plan in the event of hospitalization.
  • Keep the health care plan ID card close by, in a wallet or purse.

Emergency Care or Urgent Care?

A big part of the health insurance reform that led to managed care was the need to keep people from using the emergency room for everything except true emergency care. Treatment in the emergency room at a hospital is extremely costly. Managed care does not want members to use emergency rooms for non-emergency situations, such as the flu or an earache.

An emergency is defined as the unexpected onset of a serious condition or life-threatening injury that requires immediate medical treatment. An urgent condition needs treatment within twenty-four hours, in contrast with the immediacy of an emergency. An urgent condition can be treated by a primary care physician or at an urgent care clinic, if available. It is not always clear, however, whether a health problem is an emergency or an urgent care situation. Some managed care plans will cover only emergency care, if it turns out to have truly been an emergency. Whether or not the patient believed it was an emergency does not matter. Other managed care plans use the prudent lay person standard: the decision to seek emergency care will be covered if it is one that an average person with average medical knowledge would

MedStop is an example of a walk-in urgent care facility. It is meant to serve patients with urgent, but non-life-threatening, conditions. (Photograph by Robert J. Huffman. Field Mark Publications. Reproduced by permission.)
Robert J. Huffman. Field Mark Publications
. Reproduced by permission.)

make at the time. The decision of whether a condition is an emergency, urgent, or can wait for a regular appointment rests solely on the individual. Common sense is a good guide when all else fails.

If it's obviously an emergency, the person should call 911 (or other emergency numbers). If it is less clear and there is time, the person should call the plan's advice line, or urgent care line. When calling 911, the person should be prepared to describe:

  • ABCs: airways, breathing, and circulation. If any airways are obstructed, if breathing is abnormal or there is no breathing, and if a body part has gone numb or the person is turning blue.
  • Symptoms: where it hurts, how often, and if the person's temperature is abnormally high or low.
  • Chronology: when the symptoms started or when the accident occurred.
  • Vital extras: age of the patient, any medications being taken or allergies, chronic illnesses, and any special circumstances (such as what the person ate).

Generally, managed care plans will pay for treatment of emergencies at the nearest hospital. If a person does not have time to notify the plan in advance of hospitalization, it is important to call the plan on the following day or within twenty-four to forty-eight hours, depending on the plan.

If a person seeks emergency treatment and the plan denies coverage, the person can appeal that decision. In that case, the person should gather copies of documents and medical records from the hospital. If there were any other people present at the onset of the illness or when the accident occurred, the person appealing should get statements from these people.

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