What Happens if a Patient Goes to the Emergency Room Without Insurance?

No one ever wants to end up in the emergency room (ER). But accidents and health emergencies happen. A patient may end up needing immediate care without health insurance. 

If that’s the case, what happens?

Can an Emergency Room Deny a Patient Services For Not Having Insurance?

The Emergency Medical Treatment and Labor Act is also known as the EMTALA. The law requires a hospital to treat and stabilize anyone who goes to the ER, even if they are uninsured, and it’s unclear how they will pay for treatment. It ensures healthcare providers do not transfer these patients or deny them critical treatments.

Note that this rule does not necessarily apply to routine care. EMTALA covers emergencies. Providers can deny treatment to anyone seeking non-emergency care in the emergency room. An overburdened emergency room may turn away patients seeking a vaccine or treatment for a sore ankle.

But even under EMTALA, care is not free. All ER visits will generate a bill. If the patient or their insurance cannot pay that bill, who will?

What Does It Mean if a Patient is “Uninsured”?

Uninsured patients must cover their healthcare expenses. They do not get help from private insurance or government programs like Medicare, Medicaid, Children’s Health Insurance Program, or a military health plan. These patients either do not have insurance or choose to pay out of pocket for medical services.

Typical Demographics of Uninsured Patients

In the United States, there are 25.6 million uninsured nonelderly people. These patients are diverse in age, ethnicity, and health. Research has uncovered typical demographics among uninsured populations. Among these patients, there are racial and ethnic disparities. 

Most are adults from working, low-income families. People of color and noncitizens are more likely to be uninsured. According to the Kaiser Family Foundation, “the uninsured rates for nonelderly Hispanic (18.0%) and American Indian and Alaska Native people (19.1%) are more than 2.5 times the uninsured rates for White people (6.6%).”

Reasons a Patient May Not Have Health Insurance

Those fortunate enough to afford medical care might not understand why someone may be uninsured. But in the U.S., one out of every five adult patients receives health insurance through government-sponsored programs. This is also true for one in three children. These people are your friends, family, neighbors, or peers.

There are many reasons why people don’t have health insurance. To name a few:

An Unexpected Life Event

Any unexpected life events can change insurance eligibility factors. The most plain examples include employment, income, or family relations. People do not plan these events and may focus on coverage less depending on their circumstances.

Leaving or Losing a Job

Leaving a job can be voluntary or involuntary. Regardless, patients are no longer eligible for employer-sponsored health insurance until they find a new position.

Part-Time, Freelance, or Contracted Employment

People working part-time are generally not eligible for employer benefits like health insurance. Additionally, contractors or freelancers who run small businesses may not have health insurance.

The Expensive Costs of Premiums

Many uninsured patients report the high cost of premiums as their number one obstacle to insurance coverage. Despite federal and state efforts to curb costs, policies remain expensive. The Kaiser Family Foundation conducted a report in 2022. They found that 64% of uninsured nonelderly adults cited high costs as their primary reason for remaining uninsured. 

Lack of Eligibility for Government Programs

Some populations are not eligible for government-sponsored coverage. One example is low-income families in states that have not expanded Medicaid coverage. Undocumented immigrants are also ineligible for coverage under any federal program. This is true for programs including Medicare and Medicaid.

The Emergency Severity Index (ESI) Scale: Breaking Down the Costs

The Emergency Severity Index (ESI) Scale demonstrates the five levels of care patients may receive in the ER. It ranges from 5, indicating a more minor issue, to 1, representing severe treatments like those in a trauma center. The lower the number on the ESI scale, the higher the cost of treatment.

What Happens if a Patient Can’t Pay Their Hospital Bill?

The hospital may put unpaid bills on a payment plan or send them to a collection agency. Hospitals want to collect on accounts, so they will try to work with patients and set up payment plans before sending the account to a collector. 

Unpaid Medical Bills & The Consequences

Medical debt is America's most common type of debt - and it adds up. Patients with high unpaid medical bills could face financial problems like a lowered credit score or bankruptcy. In severe cases, high amounts of debt can extend to even more significant issues like foreclosure. 

Who Pays for Uninsured Patient Treatment?

If a patient cannot pay their bill with existing coverage, the debt may end up in one of two places.

Assistance Programs

Payment assistance programs cover treatment for uninsured patients if they meet certain criteria. Government-sponsored insurance programs like Medicare or Medicaid enroll many Americans. Many other public and private financial assistance options are available as well.

If the hospital finds that a patient qualifies for a program, they can move the account to it. Then, they can provide retroactive coverage.

Hospitals, Healthcare Providers, & Uncompensated Care

If a patient does not qualify for or attempt to enroll in one of these programs, the hospital will write off the cost of care as an expense. The hospital and the uninsured patient don’t want to shoulder the cost of care. That's why it’s in both parties’ best interest to enroll in one of these programs before the account adds to uncompensated care costs.

Uncompensated care, or bad debt, is lost revenue when a hospital provides care and does not receive payment in return. This loss can severely impact its revenue cycle and revenue recovery efforts. Hospitals plan for some level of uncompensated care costs in hospitals each year. However, too many bad debt write-offs can quickly become a financial crisis. 

Can Patients Negotiate, Reduce, or Dispute an ER bill?

Yes, patients can negotiate an ER bill. They can first request an itemized medical billing statement. Then, they can call the hospital billing department to inquire about specific charges. Existing insurance coverage might deny a charge. Or, it might be unexpectedly out-of-network. In those cases, patients have the right to at least ask for an explanation, if not a cost reduction. The key is to maintain a polite, professional, but firm conversation on behalf of both parties. 

How to Improve the Patient and Financial Counselor Relationship

Patients often dread working with financial counselors, but we must reform this distrust. Doctors and nurses assess physical health and provide medical solutions. Meanwhile, financial counselors assess financial status. Then, they determine how to provide monetary assistance.

Try to avoid comparing financial counselors with the collections department. They are not looking to take money from anyone. They want to help cover care so patients don’t leave the hospital with medical debt.

That being said, it's easy to understand the wariness of financial counselors. A patient is almost always under a lot of stress coming into the ER, especially without insurance, and the last thing they want to think about is payment. Financial counselors must remain empathetic, calm, and delicate when working with uninsured patients.

Financial counselors should examine their processes and policies to improve their patient relationships. Below are three common key areas where financial assistance departments can often improve.

Early Intervention Before a Patient Leaves

Early intervention is key in financial assistance. Once patients leave the ER, their accounts move to the billing department. It becomes exponentially more difficult for the hospital to track them down and help them find coverage. Financial assistance teams should intervene quickly after medical diagnosis and stabilization.

Early intervention comes with its own set of sensitivities. A patient may not want to talk money right after a life-saving treatment or sobering diagnosis. However, the average ER bills range from $150 to $3,000, and no one wants to leave treatment with that responsibility. Financial assistance teams should be trained in empathy. They should also familiarize themselves with the patient’s case before jumping right into finances.

Leverage Healthcare Technology & Tools

Unlike the traditional working world, the ER is not at its busiest from 9 AM to 5 PM. Instead, emergency departments see the highest volume of patients during the off-hours between 5 PM and 9 AM and on weekends. Hiring people willing to work second and third shifts is complex. As a result, these departments often work with limited staff, screening high volumes of patients.

It's essential to work around the staffing challenge and avoid making patients feel like they’re an item on a checklist. Investing in a technology solution for self-pay patient management is the best way. Interviewing patients and manually choosing the best financial assistance course is not efficient. Instead, counselors can use a screening tool that only needs the patient’s answer to a few simple questions.

Leveraging a screening tool allows for rapid assessment and faster follow-up. A good tool can also let patients authorize the hospital to represent them in the financial aid process. Doing so makes it much easier to enroll the patient in the right program even after they have left the hospital.

Improving Self-Service Follow-Up for Discharged Patients

Of course, only some patients admitted to the ER will remain there for an extended period or even overnight. Almost 90% of patients will be back home or referred to another healthcare provider without needing admission.

Sometimes, counselors cannot complete the financial assistance enrollment process before discharge. In those cases, it’s in a hospital’s best interest to follow up with the patient to continue the process. 

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At the very least, hospitals should create a system for communicating with discharged patients. Digital and print methods are the best ways to support this system. But technology is the ideal solution for improving patient follow-up. Access to a self-service portal can allow patients to fill out an enrollment application. It can also allow them to authorize a financial counselor to fill out the form for them even if they’ve long since left the hospital.

Getting Uninsured Patient Coverage Requires the Right Technology

Hospitals need a technology solution to support financial assistance screening. Integrating screening into the emergency department’s registration process is ideal. 

Leveraging technology supports counselor-patient interaction. Patients often feel cornered discussing their bill right after treatment. With the right technology, patients can decompress before approaching them at the right time. Self-service portals also allow for easier access to discharged patients. This easy access makes younger generations of patients raised on technology feel more in control of the process.

Office Ally’s MAPS software solution supports this process. It helps hospitals convert their self-pay patient population into revenue-generating assistance programs. It also helps prevent uncompensated care costs. It optimizes an increasingly challenging enrollment process. At the same time, it caters to shifting patient demographics and contributes to revenue recovery solutions.

‍Learn more about Office Ally’s MAPS for Hospitals, your one-stop shop for self-pay patient management, and Office Ally pricing.