Emergency Room Controversy: What Will Medicare Cover?

Many people wake up in the middle of the night, like my mom did a few years ago. She had classic symptoms of a heart attach and quickly called 911. Luckily, the emergency room doctor diagnoses her with heartburn. The symptoms of the two conditions share many similarities. It’s better to rush to the ER and be embarrassed later that it was only acid reflux, than be dead. On this we can all agree.

But many insurance carriers, are not pleased when a member goes to the ER for a non emergency. They are so very not amused, that they have been denying those claims. A quick Google search “insurance company being sued for non payment of ER claims” will show you that this is a widespread problem not limited to one carrier or state.

Medicaid in several states will charge a member a higher co pay for an “inappropriate visit” and then keep increasing the co pay each subsequent non emergent visit.

What’s Going on With Emergency Room Charges?

A visit to the ER is much more expensive than urgent care, sometimes as much as 10 times more.

I took my son to the ER because he was doubled over in pain for hours. He didn’t have a fever, but his stomach was painful to the touch. I expected appendicitis and came away with laxatives and a doctor who said the pain wasn’t anything to laugh about (although we were laughing). If I’d gotten a bill for that unnecessary ER visit and had to pay it all out of pocket I’d have been furious. As it was, I had to waste $500 because the kid hadn’t been drinking enough fluids.

Make Sure Your Clients Understand Both Sides

When selling health and Medicare insurance plans, you should share this with your clients. My clients have quickly responded, “are you telling me to wait till the morning and see my primary care doctor to save money—when I could die?” I am not asking my clients to do anything. I want them to know how insurance works and make their own best guess how to proceed. Urge your clients who have been hesitant to explore 24/7 Nurse Lines and TeleDoc services to give them a try. Then explain the difference between urgent care centers and ER. Ultimately your client has to make the call whether to go to an ER or elsewhere, but first they must be educated on this situation.


Sylvia Gordon and her sister, Rebecca, run Gordon Marketing, one of the nation’s largest Medicare FMO/NMA offices. They have a team of over 100 that train and support independent insurance agents in all 50 states. You can find Sylvia’s weekly posts on LinkedIn and the sisters' Youtube channel posts 2 training videos each week. Contact Sylvia at sgordon@gordonmarketing.com or 800-388-8342.


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