Differences between Emergency Room and Urgent Care

It is not easy for a foreigner to spontaneously understand the difference between these two terms, because beyond the nuance of language, in most countries, there is no difference. We think: If I need emergency care, I go to Emergency.

In the US, it is not so simple because the two terms designate different medical services dedicated to different procedures, but above all with very different costs.

A wrong decision can therefore have a significant cost, affecting your wallet or your health.

Urgent vs. Emergency Care

Some conditions are considered absolute emergencies: heart attacks, strokes, sepsis, anaphylaxis and gunshot wounds. These must be assessed and treated in the Emergency Room (ER) of major hospitals. If a patient goes to the ER, he or she will be seen by an emergency physician. If the patient's symptoms are not listed by the American College of Emergency Physicians (ACEP), the physician may decide to refer the patient to Urgent Care. In this case, even with good insurance, the ER charges may not be covered.  Conversely, if a patient goes to an Urgent Care center for a true medical emergency, the staff must send the patient to the Emergency Room, often by ambulance, at substantial additional cost and potentially fatal loss of time.  

Urgent Care Centers

"Urgent Care" could be understood to mean a place where serious medical conditions can be treated in a manner similar, if not identical, to an Emergency Room (ER). In fact, this is not the case and the definition differs in each state. Some states consider urgent care centers to be like enhanced medical offices. Other states treat them as stand-alone emergency departments, independent of a hospital department. Urgent Care may be staffed by physicians or only by nurse practitioners or physician assistants, depending on state law.  With such diverse regulations, going to an urgent care center for a medical emergency is a gamble. Unless you are aware of what the center can and cannot treat.

Cost and Coverage

The whole concept of Urgent Care was born out of rising health care costs. People often go to the emergency room when they could be seeing their private physician for much less. Insurers have long wanted to limit these unnecessary costs. They can do this very easily by limiting their coverage to the price that would have been paid in an Urgent Care and leaving the difference " to be paid by the patient ".  For example: For a simple forearm fracture, if you go to an Emergency Room, the bill may be $2000. If the insurer estimates that in an Urgent Care the bill would have been only $1000, you will have to pay the $1000 difference.   The fact that ER Care is in your insurer's preferred network will not be enough to limit this risk.  If an Urgent Care Center is not in-network, but an Emergency Room is, it could cost you less to go to the Urgent Care Center. That said, if the urgent care center visit is not deemed necessary by your insurer, you could risk paying the bill even if the facility is in-network.

Avoiding reimbursement refusal

To better manage payment incidents and insurance refusals, some ERs have built Urgent Care within their departments. Based on the initial diagnosis by a triage nurse, you will be redirected to the appropriate center for your treatment. Many insurance companies will use the hospital admission as a deciding test to determine if you were really sick enough to need emergency care. If you were admitted to the hospital after the ER visit, your insurer may reduce or waive your co-pay or deductible. On the other hand, if you are not admitted, you will likely be required to pay your full "liability." However, many patients have no choice. Their physician may not be available for a same-day visit and many urgent care centers are not open 24 hours a day. Even if you notify your insurance company that you had no choice but to go to the emergency room, they will often ignore your request to pay until a more formal complaint is filed. This may seem unbelievable to a French person, but you have to understand that we are talking about amounts of $3 or $4000.

Independent Emergency Rooms

The independent emergency room is a relatively new invention that is spreading throughout the country. Currently, about 35 states allow these independent ERs to operate. Some are not official ERs, as they are independent and not associated with a hospital. In some states, physicians are allowed to own and operate ER facilities. Free-standing ERs can be similar to an Urgent Care. They often operate in the same locations. They will not be adjacent to a hospital - at least not in the same building - and they may or may not have an ambulance entrance. Most of these facilities offer a full range of services, including a paid ambulance service to evacuate you to the hospital if necessary. While useful for those without a hospital nearby, free-standing emergency rooms may be inappropriate for people with life-threatening conditions, such as heart attacks or strokes, which can be treated more quickly in a hospital.

A word from the expatriate health insurance advisor

An ER visit bill will almost always exceed $1,000, even if you only need an aspirin. A trip to the urgent care center or a physician's office, on the other hand, will probably cost you a couple of hundred dollars for exactly the same care.

If you are covered by a local policy, the insurer will strictly enforce the rules it sets out in those policies. The concept of emergencies is clearly defined and this definition is almost reduced to life-threatening emergencies or loss of limbs. If the insurer considers that you were not in the right place, he will only pay the part he considers to be due and will leave you between 50% and 70% to pay.

To apply these penalties, they may base their decision on the complete medical file that the Emergency Room sends them with the bill. If you are covered by an expatriate health insurance policy that can work worldwide, these notions are generally less focused on the functioning of American medicine and you will be reimbursed without any particular penalty.