When E.R. Meets HMO

As the number HMOs refusing to pay for off-hour emergency room visits grows, CBS News Correspondent Jeffrey Kofman reports that for some, getting sick means fighting for your financial health just as much as your physical health.

Joanne Hamilton is a lot better than she was one weekend a year ago when she was rushed to her local emergency room with signs of a stroke. After three days of tests, she went home with a clean bill of health - and a bill for $13,000 that her HMO refused to pay.

"They said, 'Well, you didn't have the right types of symptoms to go to an emergency room," she explains. "And I said, 'Well, what kind of symptoms would you want? dead?'."

Hers is just the latest aggravation in the ongoing arm-wrestle between millions of Americans and their HMOs. On weekends and after-hours, when family doctors can't be found, some seeking medical care in emergency rooms are being told by their HMOs that theirs are not real emergencies and won't be covered.

Caught in the middle are the hospitals. At Norwalk Hospital in Connecticut, emergency services are being strained by more and more managed care patients who are arriving in the off hours. HMOs are refusing to pay bills for close 20 percent of them.

The HMOs say they are just trying to weed out abuse, but Norwalk's Dr. Michael Carius says, "I don't see people coming in who are HMO enrollees who use the emergency department for trivial problems."

According to Dr. Donald Young, Medical Director of the Health Insurance Association of America, if people really feel they have an emergency they should go to the emergency room. That's what Hamilton did; and if anyone should know, she should - she's an emergency room nurse.

She says sometimes, especially among the elderly, she sees patients who are afraid to come in because they can't pay the bill if their HMO refuses it. But Hamilton wouldn't take no for answer. It took almost a year of calls and letters, but her HMO did eventually pay up.