when is it an emergency

Emergency Care Coverage FAQs

90% of patients sent to the emergency room underestimate the severity of their conditions

Recent health insurance policy changes and rising deductibles have caused many Texans to be uncertain about their health insurance coverage, especially when it comes to emergency care. Due to this climate and the fear of surprise bills, many people hesitate to seek emergency treatment, even if their symptoms are severe. Unfortunately, this frequently exacerbates their condition and delays necessary, potentially life-saving treatment.

We, The Emergency Center, are here to set the record straight and eradicate emergency coverage concerns for our patients. There are State and Federal Laws protecting a patient’s coverage in an emergency, regardless if the emergency facility or physician are in their insurance provider’s network. The Prudent Layperson Standard states that emergency care is to be covered for any patient (i.e. a prudent layperson) who thinks his or her health is in, or could be in, serious jeopardy, whether or not that care is provided at an in-network or out-of-network emergency facility. Prudent Layperson Standard laws were “spurred by incidents of patients with genuine acute illness who delayed care for fear of being stuck with the hospital bill”, said John C. Nelson, MD, president-elect of the American Medical Association. The Prudent Layperson Standard requires health insurance companies to cover visits based on the patient’s symptoms, not the final diagnosis. This means if a patient has chest pain, but turns out to have a non-urgent medical condition, the insurance company must still cover the visit. Texas Law also requires all emergencies to be processed and paid by insurance companies as In-Network. To put it simply, if you think you may be having a medical emergency, your emergency treatment will be covered under your insurance policy, per Federal AND State Law.

So what if you’re not sure? How do you know when to go to an urgent care vs an ER? You’re not alone. Most patients lack the medical knowledge and training to determine the cause of their symptoms and shouldn’t be expected to self-diagnose their medical conditions. Two people may have identical symptoms but have different diagnoses — one life-threatening, one non-urgent. Not to mention, there is nearly a 90-percent overlap in symptoms between emergencies and non-emergencies, according to a study in the Journal of the American Medical Association.

We are here to carry the burden of that decision for you. Don’t hesitate to seek emergency care if there’s the slightest chance you’re having an emergency. Come in and let our Board Certified ER Doctors diagnose whether you’re having an emergency, and if you aren’t, we will facilitate your referral to an urgent care that’s right for you. If you are having a medical emergency or need more advanced testing than an urgent care offers, you will have come to the right place. By coming to us first, you avoid potentially paying for an urgent care and an ER visit. As they say, it’s better to be safe than sorry.

If necessary, our dedicated patient advocate will work with you and your insurance to ensure you’re not stuck paying for emergency treatment that is covered by your insurance plan. We will make sure your insurance pays for the treatment you and your doctor felt was reasonable, necessary, and required for your care.

These laws apply to commercial insurance providers. Unfortunately at this time we do not accept any government managed health insurance, such as Medicaid, CHIP, Medicare or Tricare, as the state does not allow this. We do, however, offer self-pay rates at a significant discount for those patients needing care who have those plans or do not have insurance.