Emergency care and medical insurance

When a person comes to the hospital’s emergency department after a fall at home, with complaints of neck pain, is this an emergency or urgent care situation?

If the person is examined and found to have a sprain, without any serious medical conditions, it most likely is considered urgent care.  

The patient is offered further care after he or she prepays for services, with the understanding that no further care will be given unless the patient provides insurance information or money. Patients are told that they can seek care at the community clinic if they cannot pay or lack insurance.

If the injury to the neck caused significant internal damage and restricts breathing, resulting in the need for immediate surgery, it most likely is an emergency. In an emergency, the inability to pay does not delay required surgery. Here is why.

When a patient comes to a hospital’s emergency department, the patient is protected under the Emergency Medical Treatment and Active Labor Act (EMTALA) of 1986.

EMTALA was designed to legally obligate hospitals with emergency departments to examine, stabilize and when able, to treat, all patients with diagnosed emergency conditions, including the uninsured or Medicaid patients.

EMTALA protection is also described as the “anti-dumping law” (a more detailed description can be found under “Frequently Asked Questions” at http://www.emtala.com/).

The hospital is responsible for costs of EMTALA- mandated emergency care. EMTALA does not require health insurance companies, governments or individuals to pay for mandated emergency medical services.

A summary of the EMTALA website explains three main obligations given to hospitals with emergency ��@departments:  

1) Any individual who requests emergency services must receive a medical screening examination to determine if there is an emergency medical condition.

2) If an emergency medical condition is diagnosed, it must be treated until it is resolved or the patient is stabilized. If the hospital is incapable of treating the patient, the patient must be stabilized and transferred to a hospital that can provide adequate treatment.

3) The hospital with the capacity to treat the patient is obligated to accept the transfer. If the patient is transferred in an unstable condition, this must be reported to the CMS as a violation of EMTALA.

Even with health insurance, some managed care plans do not cover emergency services due to the final diagnosis, and sometimes require a pre-approval before seeking medical care.