Emergency room visits may cost members money

Published Nov. 30, 2006
By Capt. Erin Vanderwall
325th Medical Group

TYNDALL AIR FORCE BASE, Fla. -- If members visit the emergency room without proper cause, they now
may have to foot the bill.

ER visits are for true emergencies such as the possibility of loss of life, loss of limb, loss of eye sight, severe pain, fractures, head trauma, and children with significant fever. No beneficiary in an emergency situation needs to contact their Primary Care Manager prior to calling 911 for an ambulance or proceeding to the ER.

If unsure about going to the ER, call the clinic at 283-2778 to ask someone from the PCM team or the on-call provider (after clinic hours) to discuss symptoms and conditions. They will help determine if the ER is the appropriate level of care required.

It is important to know that some legitimate ER visits may be coded as a non-emergency. An example would be visiting the ER for chest pains, and discovering the pain was caused by heartburn. The patient will receive a bill as a result. Take the bill to the Tricare Service Center within 30 days to appeal based on the Prudent Layperson
Standard. This standard determines if the situation would have caused other reasonable adults to think that this was a risk to life, limb, or eyesight, then Humana Military Health Services will override the non-emergency codes and reprocess the bill as an emergency. The Tricare Service Center is located by the main pharmacy on the first floor of the clinic.

Beneficiaries should note that nonlegitimate ER visits for things such as birth control refills or minor illness that could wait until the next duty day or would more appropriately be seen in an urgent care center may not be accepted during an appeal.

If Humana determines that the ER visit was not appropriate using the Prudent Layperson Standard, the sponsor may be financially responsible for point of service charges incurred for that visit. If patients do not need an ambulance, but are unsure if about going to the ER, he or she should talk to the PCM team or the on-call provider
for advice.

Follow-up visits after a discharge from the ER or hospitalization, urgent care center visits, or recommendations from a current specialist to seek additional specialty care all require prior authorization. Call the clinic prior to obtaining these services, and a health care provider will advise you and set up the necessary referrals. If chosen not to follow this plan of care, point of service charges may apply to unauthorized care received outside of the Military Treatment Facility.

Active duty members are required to receive authorization for all care received outside of the MTF. Active Duty ER retroactive authorizations can be obtained by calling the clinic after your situation stabilizes, regardless of the diagnosis.

All active duty patients receiving bills for any type of care should visit
the Tricare Operations and Patient Administration flight on the third floor of the 325th Medical Group or call 283-7331 for assistance.

For more information on this policy or other benefit issues, visit the Tricare Service Center located next to the main clinic pharmacy, or the TOPA flight on the third floor of the main clinic.