According to the Centers for Disease Control and Prevention report, every year, around 139.8 million patients visit emergency rooms in America. This large number depicts the value of effective emergency room medical services. During urgent medical situations, emergency room services stand as a vital lifeline, providing immediate and critical care. This blog will help you understand what emergency room billing is.The process steps, coverage it provides, misconceptions and reality, major challenges, and solutions.

Understanding Emergency Room Billing

Emergency room billing is the process of submitting claims to the healthcare payer for the services rendered to the patient in an emergency room. The bills cover a whole set of charges associated with the medical services provided, including the facility fee for the operational cost of an emergency room as well as charges for professional services rendered by visiting a provider. Other services, such as laboratory tests, radiology, and medications, also contribute to the overall bill.

The Journey of Your Bill: From Information to Insurance Provider

Journey of your bill

Provider’s Information during an ER Visit

The billing process starts when a patient visits the emergency room. All the basic information related to the patient, as well as his insurance data and history, is collected. The diagnosis, procedure, treatment, and all other crucial data are gathered by the healthcare provider.

Medical Coding and Documentation

Coders assign the specific codes to the services rendered in an emergency room. These codes set the accuracy of the medical billing and coding process. The coded information is documented as a medical record, which is fetched electronically or manually.

Claim Submission to Insurance Company 

The insurance company reviewed the submitted claim for validity and policy coverage for the patient. If it meets the guidelines of the company, reimbursement is transferred to the healthcare provider. The insurance company also checks the patient’s deductibles or copayments.

Notification to the Patient

The insurance company also sends an Explanation Of Benefit (EOB) to the patient. The EOB covers the details of the total amount, deductibles, copayments, and reason if the claim is denied due to any reason.

Responsibility of the Patient

A bill statement is sent to the patient by the healthcare provider. This bill states the remaining balance that must be paid by the patient. The patient has a responsibility to pay the remaining amount within the time given by the provider.

Resolution and Follow-up

If the remaining balance is difficult for the patient to pay, he can negotiate payment plans or demand financial assistance from the healthcare provider. He can also initiate an appeal process for the denied claims.

Everyone Receives Emergency Room Benefits: Understanding Coverage

Emergency room benefits are extended to anyone with a healthcare insurance plan. Anyone, regardless of age, gender, or background, is entitled to ER services. These services are for emergency situations where prompt medical action is required.

The health insurance plan covers urgent care as the company considers the unpredictable nature of the medical emergency. The insurance plan coverage includes visits to the emergency room, provider fees, diagnostic tests, procedures, and necessary treatments.

 According to a survey conducted by the Kaiser Family Foundation in 2021, 94% of healthcare insurance plans cover emergency room services under the Affordable Care Act (ACA).

Common Misconceptions About Emergency Room Services

Misconception 1

Emergency- Room Services Cover only Life Threatening Situations

Reality: A health insurance policy is not limited to life-threatening conditions. It covers a wide range of situations which requires immediate attention and care. situations include severe injuries, sudden illnesses, etc.

Misconception 2

Pre-authorization is always required

Reality: Emergency room situations demand prompt action, so a pre-authorization is practically not possible. Insurance plans exempt authorization for emergency visits and are only applicable to non-emergency services.

Misconception 3

Insurance Coverage Depends on the Hospital’s Network Status

Reality:The health insurance plan provides coverage for emergency rooms without considering the network status, whether in-network or out-of-network. This is important as patients can get the facility at the nearest hospital without worrying about the network status.

Do You know?

The British Medical Journal presented its report in 2016. The report states that 5%–10% of emergency room visits show errors. This means that out of 140 million emergency room visits, more than 10 million visits have errors.

Standalone Emergency Rooms: Simplifying the Billing Process

Standalone emergency rooms are independent medical facilities that are not attached to any hospital. These emergency rooms help to provide prompt and effective patient care, accessible to all kinds of emergency services.

Advantages of Standalone Emergency Rooms, such as Advance ER

Advantages of Standalone Emergency Rooms, such as Advance ER

Accessibility and Convenience 

Standalone emergency rooms such as the Advance ER are located in a place that is convenient and easily accessible to patients. Their proximity to communities reduces the hassle of driving hours to the hospital in a critical condition.

Transparency in Billing

Standalone ER is transparent in nature. The direct and clear billing practices help to understand the costs associated with the emergency services rendered to patients.

Single Facility Fee

Standalone ER makes it simple for patients to understand the billing process as only a single facility fee is charged, which constitutes various services. In a hospital, patients have to deal with multiple bills charged by different departments.

Insurance Coverage

Standalone ER accepts a wide range of insurance plans. Thus, the patient does not need to worry about the insurance coverage. The patient can utilize its insurance policy without any network restrictions.

Specialized Care

Standalone ERs are well equipped to handle a wide range of emergencies. The emergency room offers specialized care to patients with the help of a dedicated staff and advanced medical equipment.

Challenges for Emergency Room Billing

Here are some challenges faced by emergency rooms in billing and their effective solutions:

Challenges

Insurance Coverage and Network Issue

Many insurance companies avoid providing coverage to emergency doctors. Patients who receive emergency care from out-of-network providers face the challenge of out-of pocket expenses.

Surprise Billing 

Surprise billing is the difference between what the insurance company covers and the total charge incurred by emergency room services. The discrepancy between the emergency room bills and insurance coverage puts an unexpected financial burden on the patient.

Timely Documentation

The emergency room demands prompt action. Documenting patient data is challenging for providers. Incompletion or delays in documentation result in claims being denied by the insurance companies.

Lack of Price Transparency

Lack of price transparency in the healthcare industry, including emergency rooms, is a setback for patients, as they are not aware of how much they have to pay until they receive the bills.

Effective Solutions 

Legislation to Address Surprise Billing

 Supporting legislative measures that can address the issue of surprise billing is the best approach to tackling surprise billing. This helps protect the patients from unexpected out-of-network bills.

do you know

Enhanced Price Transparency

Enhanced price transparency helps to provide patients with a clear and accurate image of the costs associated with the emergency services rendered. Strategies include standardized price lists, online price tools, and insurance estimators that help the  patients to  estimate and compare the expenses of different emergency room services.

 Standardized Billing Practices

Standardized billing practices are a crucial component of streamlining emergency room billing. This approach is effective if  the provider  adopts uniform coding, shows transparency in charge breakdowns, and consistency in presenting bills to patients.

Outsource to Medheave: A Leading Medical Billing Company

Medheave is a medical billing company specializing in revenue cycle management for various medical specialties, including emergency room services. The company is aware of the complex billing requirements for emergency services. A team of professionals at Medheave has an updated knowledge of rules and regulations, documentation required, modifiers used, and how to successfully submit a  claim to the insurance company. Contact us today to ease your billing complications with Medheave.