To ER or Not to ER? How you might save thousands of dollars

Michael E. Makover, MD FACP, Chief Medical Officer JIBEI

Misunderstanding how your health plan covers the use of the Emergency Room might cost you thousands of dollars. Learn how your Plan works and how you can give yourself the best chance for using the ER most effectively.

ERs are very expensive

Emergency rooms are one of the most expensive services in healthcare. A simple cold seen in a doctor’s office may cost perhaps $100 or less. That same care in the emergency room could cost over $1,500, sometimes way over that.

When you need them, ER’s can be lifesaving. However, too often today they are used as if they were primary care doctors’ offices.

 How your benefit plan works

Your benefit plan covers ER visits that are for “Sudden and serious diagnoses”. That means something:

  • That has troubled you for usually less than 24 hours
  • Cannot be handled in a doctor’s office
  • Cannot safely wait for a doctor’s office to open
  • Or, is so serious or life threatening that it cannot wait at all.

How can you be sure? You are not expected to be a medical expert.  Thus if you go to the ER fearing a serious illness that suddenly came on, most likely that will not be questioned. However, if you had those symptoms for many days, or could have gone to your doctor or an urgent care office first during the day, or could have waited for the next opening at the doctor’s office, then it might not be covered.

If your visit does not meet the standard, then you will have to pay the ER yourself, very often more than $1,000.  

If you can, call MagnaCare beforehand (877-624-6210). They can give you some idea of if it will be covered, though that is not binding since they have limited information by which to judge. You will still need to think carefully about whether to go or to wait. If not beforehand, try to call from the ER or within 24 hours afterwards.

Never delay going to the ER when it is a true emergency! Much worse than going to the ER when it is not necessary would be not going when you really do need emergency care.

Thus the difficult choice – to ER or not to ER?

Here are some things you can do if it is not an obvious immediate need for emergency care: 

  • Call your doctor, even after hours. Doctors often have another doctor taking their calls when they are not available themselves evenings or weekends.
    • However, your doctor will not be able to tell you whether an ER bill will be reimbursed.                                                                                                           
  • Think ahead. We are all very distracted by our busy, stressful lives, but this is very important, so plan ahead before it gets to the evening or the weekend if it is something that you think might get worse.
  • For example, If you see that the cold that began on Tuesday is not getting better toward the weekend, call your doctor no later than Friday morning and ask what you should do if you get worse over the weekend.                                                                                                                                                     
  • Do not go to the ER just because it seems more convenient or because you do not want to take time off from work during a workday. That might end up costing you much more than a day’s wages.                                                                                                                                                                                  
  • If you do not currently have a primary care doctor, it is probably best to have one. Urgent problems, whether requiring an ER or not, by definition arise unexpectedly and usually very inconveniently, so having a doctor you know is better than scrambling for one at the last minute.                                                 
  • Local urgent care centers and some doctor’s offices have late hours and weekend hours. Calling MagnaCare can help locate one for you. Even if the facility is not in MagnaCare, it might be much less expensive than a denied ER bill. Look up MagnaCare's Urgent Care Center Information Reference  online.

 NYC Boroughs and Long Island Urgent Care Centers. Go to MagnaCare's Urgent Care Center Reference, and select NYC Boroughs Long Island for a more updated list of new centers.                                                                                                                                                                          

  • Call Health Advocate (Enter JIB Local 3 as the organization name) 866-799-2723, another agency JIB provides you access to. They can advise you and help find a non-ER facility to for you.                       
  • If you do end up having to pay an ER bill out of your own pocket, talk to the hospital to see if you can negotiate a lower cost settlement.                                   

Your health plan understands that these choices can be difficult sometimes and it gives members as much leeway as possible. However, remember also that the decisions are made simply on the basis of how to use your dollars to give the most benefit to the most people.