When accidents, incidents, and illnesses arise, finding the best type of health care provider for your needs can be tricky.
If you sprain your ankle during a weekend soccer game, should you go to the emergency room? Can your primary care physician treat accidental poisoning? And what exactly is an urgent care center?
For non-emergency situations, it’s best to go to your primary care doctor or clinic for care. Your doctor knows you and your health history; has access to your medical records; and can provide follow-up care or refer you to specialists if necessary. Many primary care clinics offer extended hours and weekend appointments. And most clinics have staff on-call after hours that can help you get the care you need.
Convenience care sites (MinuteClinic® and Target Clinic, CVS or Walgreens Clinics are examples) usually are located in grocery stores, shopping malls, pharmacies and other retail stores.
Convenience care sites are staffed by licensed providers who can diagnose and recommend treatment for certain minor illnesses such as sore throats and ear infections for people older than 18 months.
If your primary care physician is not available and you need quick medical attention for a non-life-threatening problem, visit an urgent care center.
What: Urgent care centers have similar resources to primary care facilities, but they provide comprehensive quality care on a walk-in basis with extended hours.
When to go: Go to an urgent care center when you need immediate medical attention or have non-emergency health concerns after hours. Examples include ear infections, sprains, simple cuts and burns, and eye injuries.
These clinics can usually handle problems that need immediate attention but aren’t life-threatening or emergencies, like stitches, sprains and x-rays.
Urgent medical conditions are ones that are not considered emergencies but still require care within 24 hours. Some examples of such conditions include:
Life-threatening emergencies and late-night trauma require an immediate visit to the hospital.
What: Emergency rooms offer inpatient care, emergency services, trauma services, and more. Emergency clinicians are able to recognize, diagnose, and make recommendations for a wide array of medical issues.
When to go: Call 911 or drive to the emergency department at your nearest hospital whenever conditions cause severe symptoms and/or put your health at serious risk. Examples include heart attacks, poisoning, severe bleeding, and broken bones.
Some examples of conditions that require emergency medical care include:
Unless it’s a true emergency, you’ll likely get quicker medical care at other care settings such as an urgent care center, retail health clinic or walk-in doctor’s office. Use these options, where available, when you need medical care quickly, but can’t see your regular doctor. These conveniently located, licensed and accredited care settings are staffed with doctors, nurses and physician’s assistants. So you’ll get quality care, and you’ll often pay much less than you would for emergency care. And they’re usually open evenings, weekends and sometimes holidays, and can cost about the same as a doctor visit.
Retail health clinic: Many major pharmacies and retail stores now have these walk-in clinics staffed by medical professionals. Go there when you need convenient, routine care, like for coughs and flu shots.
Walk-in doctor’s office: No appointment is needed at these offices, and you usually aren’t required to be an existing patient. This alternative is a good choice when you need simple medical care in a hurry, like for mild asthma or minor allergic reactions.
Your health plan may have a 24/7 nurse line that you can call for assistance in determining the severity of your symptoms and where to go for care.
In Network vs. Out of Network Charges. Fair Health Consumer.org –
For instance, your insurer’s contracted rate for a primary care visit might be $120. If you have a $20 co-payment for primary care visits, you will pay $20 when you see a doctor in your network. Your insurer will pick up the remaining $100.
If you go outside your network, it’s a different story. You will likely pay more if you go “out-of-network” for your care. That’s because:
Providers outside your network have not agreed to any set rate with your insurer, and may charge more.
Your plan may require higher co-pays, deductibles and co-insurance for out-of-network care. So, if you normally have to pay 20% of the cost of the service in-network, you may have to pay 30% out-of-network. Often, you’ll have to pay that PLUS any difference between your insurer’s allowed amount and what the provider charges.
Your plan may not cover out-of-network care at all, leaving you to pay the full cost yourself.
Questions To Ask Your Provider (if insurance is an option) – Fair Health Consumer.org
Don’t forget to bring your plan ID card to your appointment!
Do you participate in my plan’s network? If not, how much can I expect to be billed for my visit?
Will my insurance plan’s payment cover the full cost of this out-of-network visit? If not, will you expect me to pay the difference between your bill and what you are paid by the insurance company? If you participate in another network, are you willing to accept their payment amount as full payment for this visit/service?
Will you file claim forms for out-of-network services on my behalf?
What tests/lab work will be ordered for my visit? Will they be covered by my health plan? If performed elsewhere, are the facilities performing the tests/lab work considered “in-network” under my plan?
Will your office check with my plan to determine if pre-authorization is required for any tests or procedures?
Will you be performing or ordering services not typically covered by my plan?
Can you tell me which procedure codes you will likely submit for the services I will receive? (CPT® or HCPCS codes for medical; CDT® codes for dental)
Do you offer payment options, discounts, or otherwise negotiate your fees, for services that are out-of-network or not covered by my plan?
Are the medications you prescribed covered by my plan? If not, is there a less expensive alternative such as a different brand or generic option that is covered? If you are prescribing a drug that must be administered in the physician’s office, is there an alternative such as a pill or injection that can be self-administered?
Will my surgery/procedure be performed at an in-network facility? Will all of the providers (anesthesiologist, radiologist etc.) that I see at the hospital or outpatient facility be part of my plan’s network? If not, can you provide me with contact information for these providers so that I can obtain information to help me plan for my health care expenses?
Make a note of the date and the name of the person(s) you spoke with.
Consumer Reports – Urgent Care-What You Need To Know – April 2009
Urgent Care – Cost? Moderate—comparable to most doctor visits (around $120), but much less than ER care. And the insurance co-pay is likely to be lower than an ER too.
Retail Clinic – Cost? Low—$55 to $75 on average if you pay out of pocket, or a regular office visit co-pay if your insurance covers it.
Emergency Care – Cost? High—$400 on average.
First Person: Which is Cheaper Out of Pocket – Urgent Care Facility or Hospital ER? – Yahoo Answers – February 201
With two kids and an accident prone adult, medical emergencies such as lacerations, broken bones, or insect bites would probably be unavoidable in our family. As long as anesthesia is not required, an urgent care facility will likely be more bang for my healthcare dollars. Most urgent care facilities are staffed by former ER doctors and nurses, so the quality of care is at par with hospitals. However, not only are they much more prompt, but it also makes financial sense given the one-time, low cost of using an urgent care facility, even one that does not accept insurance.
Your Doctor Is In Isle Four – CNN Money – December 30, 2008
Retail clinics, online docs and other new health-care options aim to deliver fast, reliable treatment, no appointment necessary. And you might be able to pick up some groceries at the same time.
Best for: Simple ailments (like strep throat or pinkeye), plus preventive care (flu shot or blood-pressure check)
Price: About $50 to $75 a visit
Insurance coverage: Usually, but check with your carrier.
Best for: Preventive care (immunizations and screenings); basic ailments; disease management
Price: Typically $0
Insurance coverage: Yes
Best for: Acute conditions that need quick attention but aren’t life threatening (a sprain or a sliced finger)
Price: About $80 to $250 a visit
Insurance coverage: Most centers accept the major health plans