If you unnecessarily visit an ER in lieu of a visit to your Primary Care Physician (PCP) or urgent care facility, coverage may be denied. In that case, a member is responsible for 30% of the allowed amount after the deductible is met.

As SWSCHP has studied this challenge, we’ve concluded that it is important for our members to have a clear understanding of when to actually use an emergency room.

Frequently, we will hear from our members that their primary care physician’s office was closed, which forced them to an ER. But if there is no serious or life-threatening condition, SWSCHP members should visit an urgent care center. Members can also use the telehealth services available to get certain medical care by phone or online, and to help them determine if they need ER care.

How do you know to go to the urgent care center? Here are some examples:

• Your problem is not life threatening or does not have the potential to cause disability, but you are concerned and your doctor’s office is not open.

• You are experiencing a common illness (cold, flu, earache, headache, sore throat, fever, rash) or minor injury (sprain, cut, burn, back pain, eye injury) that does not require an ER.

We know that ‘concern’ is different for each person. But that’s why the doctors at an urgent center are so useful. They can quickly assess your issue and if necessary, will tell you to get to an ER. Isn’t that better than waiting for hours in an emergency room?

That’s why we suggest you find an urgent care facility (preferably one that is open for 24 hours) close to your home. Just check on the Empire BCBS and Aetna websites to ensure that they are in-network.

What Constitutes an Emergency?
So how does one assess whether to immediately go to an emergency room? Injuries like broken bones that result from accidents or concern that one is having heart attack symptoms are two very common ER visits. Often, it is the question of clear urgency that requires a visit to the ER.

The US National Library of Medicine has an excellent checklist that you can review here.