Approximately 2,000 PWGA Participants go to an ER in a typical calendar year. Often, it’s for relatively modest issues: a high fever, a fractured limb, an accident, or sports injury. Sometimes, it’s for more important things like a heart attack or possible stroke. Whatever the reason for going to an ER, there are financial considerations. If you take them into account in advance, you may be able to save yourself financial trauma later.
The PWGA has recently increased the out of pocket maximums to $20,000 when a Participant is using out-of-network services. Most Participants take this into account when they seek medical services, but the one place where Participants usually don’t ask questions is when they are seeking treatment in an ER.
The example below posits an ER visit for a Participant where he/she is involved in a bicycle accident that results in a broken arm and a surgical repair. By using in-network services, the Participant’s total responsibility is only $693.53 (from a total bill of over $12,000). If the Participant uses out-of-network providers, his/her responsibility on the same bill, for the exact same services, is $2,150.99.
In-Network
| Type of Service | Charge Amount | INN Allowable Amount | PWGA Paid Amount | Patient Responsibility |
|---|---|---|---|---|
| Emergency Room Physician | $ 772.00 | $ 224.50 | $ 190.83 | $ 33.68 |
| Anesthesiologist | $ 3,960.00 | $ 1,768.47 | $ 1,503.20 | $ 265.27 |
| Surgeon | $ 7,980.00 | $ 2,610.42 | $ 2,218.86 | $ 391.56 |
| Radiologist | $ 27.00 | $ 20.13 | $ 17.11 | $ 3.02 |
| Total | $ 12,739.00 | $ 4,623.52 | $ 3,929.99 | $ 693.53 |
Out-of-Network
| Type of Service | Charge Amount | OON Allowable Amount | PWGA Paid Amount | Patient Responsibility |
|---|---|---|---|---|
| Emergency Room Physician | $ 772.00 | $ 706.00 | $ 600.10 | $ 171.90 |
| Anesthesiologist | $ 3,960.00 | $ 3,017.34 | $ 2,564.74 | $ 1,395.26 |
| Surgeon | $ 7,980.00 | $ 7,837.67 | $ 7,396.17 | $ 583.83 |
| Radiologist | $ 27.00 | $ 27.00 | $ 27.00 | $ — |
| Total | $ 12,739.00 | $ 11,588.01 | $ 10,588.01 | $ 2,150.99 |
Obviously, no one wants to pay thousands of dollars more than they have to, so how does a Participant protect him/herself in an ER situation? The most immediate answer is to prepare.
In the bicycle example above, it’s as simple as asking a few questions: “Is the surgeon you are recommending in-network?” “Is the x-ray technician in-network?” “The anesthesiologist?” If the answer is “No”, most of the time an ER can use a provider who is in-network. All you have to do is ask.
But what if the Participant is in pain, or unconscious? There may be some situations that are so acute it is not possible to advocate on your own behalf. But if you have a spouse or significant other who is accompanying you, if you have discussed the issue with them in advance, they will be aware of the issue and may be able to make sure you get in-network service providers.
It is not always going to be possible to insist on in-network service providers when you make a trip to the ER, but if you know there is an issue, and the possibility of getting an in-network service provider can save you thousands of dollars, the very fact that you are aware there is a choice puts you in a much better position to protect yourself financially.
Here’s hoping you never have to use this information!