Patient Protections in Managed Care - Access to Emergency Services Access to Emergency Services Disagreements between consumers and health plans often arise about what constitutes an emergency need for care. A common example is when an individual experiences severe chest pains and goes to the emergency room believing he is having a heart attack.
Tests reveal that the problem is heartburn.
In cases like this and others, managed care plans have refused to cover the cost of the emergency room services because the diagnosis was not a life-threatening event, even though the individual believed it was. To eliminate this problem, consumer groups are calling for a standard definition of the need for emergency room services. Under this definition, the basis for an emergency would be determined by what the average person reasonably thinks constitutes an emergency, given his or her condition. Plans would be required to pay for services, without regard to prior authorization or participation status of the facility.