Should a Medicare HMO pay for out-of-network emergency care?

June 6, 2008

I accept Medicare patients, but I don't participate in any private health plans. When I'm called to the ED to perform surgery on a patient covered by a Medicare HMO, who's responsible for paying me?

I accept Medicare patients, but I don't participate in any private health plans. When I'm called to the ED to perform surgery on a patient covered by a Medicare HMO, who's responsible for paying me?

If the services you provided-as an out-of-network provider-fit the CMS definition of "emergency" or "urgently needed" care, the patient's Medicare HMO should pay you, and it should do so at the participating provider rate.

Emergency services are required immediately to prevent serious harm to the patient's (or the patient's unborn child's) health, or serious impairment to bodily functions. Urgently needed services are those provided when there's no serious danger to a person's health, but an unforeseen illness or injury requires immediate care that, under the circumstances, cannot be obtained through the insured's health plan network.

This answer to our reader's question was provided by Barbara Pappadakis,Union Pacific Railroad Employes Health Systems, Salt Lake City.

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