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Italy ER visit

I recently took a hard fall in Rome (cobblestone/concrete transition) and landed on my face. A bad day, but near the end of the trip, thank god. Ended up in an ambulance for a once over, they released me and we went by taxi to an ER since I was experiencing amnesia and pretty intense pain. CAT scan showed no bleeding or breaks, and I was released. Overall, very lucky!

My question: They asked for my passport for ID, but no request for insurance info, money, etc. We had an Italian friend who was able to interpret for us with the ER nurse and they sent me on my way with instruction to return if anything more popped up. Will I ever see a bill? There is a difference of opinion amongst my friends, and I'm wondering if anyone has experienced anything similar? Did anyone ever bill you?

Posted by
2566 posts

Took a student by ambulance to the ER in Rome a few years ago for a similar face plant, unconscious, chin split fall on some marble steps in our hotel. She was in the ER for most of the day then released and she never was asked to pay anything or show anything other than her passport.

Posted by
4530 posts

Hope Springs,

Ouch! I'm sorry this happened to you... I hope you recovered completely.
I don't know the answer to your question but I'm sure someone else will.

Posted by
255 posts

No, you don't have to pay anything. Of it had been something very minor, not considered worthy of an ER visit, you would have had to pay the ticket, but not in your case! Glad you are ok!

Posted by
11613 posts

Confirming previous post info, from personal experience. Intense pain from an ear infection, ER visit, paid equivalent of $30 for everything, including meds.

Posted by
213 posts

I had a friend who was in Rome with her family - including a teenage daughter with very bad walnut allergies. They were very careful in every restaurant and over 2 weeks had no problems. Three days before the end of their trip while in Rome they visited a small family run restaurant where they inquired about nuts - specifically walnuts and were assured that the kitchen only used pine nuts. Unfortunately less than 1 minute after swallowing a mouthful of pesto pasta the teenager show extreme signs of anaphylactic shock. They had her EPI pen and immediately dosed her. An ambulance was called , arrived in 2 minutes and in 7 minutes she was in the ER being treated. My friend could not believe the speed, efficiency and compassion of staff.
Her daughter was released later that evening and my friend worried about how/where she would be able to find additional EPI pens. When she asked the nurse about it she was told that the doctor had already arranged for 3 EPI pens to be given to them.
When my friend then asked about charges for the ambulance, ER visit and EPI pens she was told there would not be one. It was considered an emergency and it was "free".
Even here in Canada - home of "free" healthcare that is amazing.

Posted by
11613 posts

Keith, if you lived in the US you would be amazed. An ER visit (no treatment) can cost hundreds of dollars, sometimes/often not 100% covered by insurance.

Posted by
27 posts

Wow! Thanks for all the responses and info! Yes, I'm doing quite well and my bruises are almost faded...only a few of the worst are still purple and green. :-)

This makes more sense now...I was classified as Yellow, so apparently it's free. Woo hoo!

And yes, Keith, if you lived in the US you would understand why we expect to pay a fortune for an ER visit even with insurance. It makes little sense from the perspective of the rest of the civilized world. I won't go on, but count your blessings! ;-)

Posted by
6235 posts

The service is not free - it requires labor, equipment, and resources, which have monetary value. The cost is spread among Italian citizens who fund their health system through their taxes (I assume payroll taxes). It sounds like they're not set up to collect from individuals who are not paying into the system (i.e. tourists). I wonder what would happen if more intensive care was needed, like multiple day hospital stays...would they just eat those costs and let Italians pay for it? Those would be billed in the multiple thousands if they occurred in the US.

It seems odd that they would go after you full throttle if this was a rental car ZLT violation (there are lots of threads about this on this forum), but not reimbursement for medical services? In any case, I'm going to bet you won't see a bill. They probably write it off as charity care or something like that. I have no idea how travel insurance fits into this...it doesn't seem like it's being invoked for its purpose.

Posted by
27 posts

I did buy travel insurance and would have been happy to pay for the great service I received. And I definitely understand that service wasn't free and how it's funded. We have family in the UK and Canada. My real question was whether I would see a bill.

Posted by
255 posts

It's not odd, when you enter a ZTL you're violating a road law, the same as when you speed, whether you're Italian or a tourist. Access to healthcare is a right, and if you need it you get it. I don't know what would happen with a hospitalization, though.

Posted by
6235 posts

If it's considered a right for everyone, including non-citizens (whether they are tourists, refugees, etc.), then everything makes sense in that context. That's a good clarification.

Posted by
23833 posts

It is called social medicine. Provided by the state to all in need. Like here in the UK, cradle to grave (mostly). You are part of society even if only temporarily, and you had a need.

My wife face planted in Cambridge (the UK one, not the suburb of Harvard University) this week and had nurses from the surrounding university assist initially, then a paramedic, and then the ambulance, and then later a visit to our local emergency for new bleeding, and all any of them wanted was to provide the care, and then ask her name and the name of her doctor so that the records could be transferred. That- despite all the critics from around the world - is a system which works.

Posted by
1352 posts

Nigel, Most of us WISH we had a system like yours. We have insurance. I had an ER visit earlier in the year. Cost me about 1400.00 out of pocket. My insurance doesn't really cover anything until I meet my 5,000.00 deductible:(

Posted by
1768 posts

ER is free for all EU citizens, if they are given either a red or a yellow priority code or if they have any kind of head injuries. It's free also for the citizens of those countries who signed a reciprocity agreement with Italy. I'd be quite surprised if US and Canada hadn't signed one.

An alien with no id and no permit to stay is recorded in the system as "don't waste time trying to get money from this one". I know at least one tourist who did not tell the nurse she had a travel insurance and was recorded as an alien with no documents to make her save the money.

Posted by
11981 posts

As far as I know, citizens of countries outside the EU or from countries that do not have a reciprocity agreement with Italy (and the US does not, since there is not a national health system here) must pay the urgent service in full at the time of discharge according to the regional fee schedule.
That is true for Tuscany (the national health service is run by each region) and also for Lazio (I just checked their website).
If hospital staff there like to give breaks to tourists, regardless of what the rules say, then it’s just another story.
The countries with reciprocity agreements are listed here in the website of the Italian Ministry of Health
http://www.salute.gov.it/portale/temi/p2_5.jsp?lingua=italiano&area=Assistenza%20sanitaria&menu=paesi

Posted by
6235 posts

What Roberto wrote makes the most sense. Why should a tourist who is not covered by a reciprocal agreement, or does not have an EU card like the European Health Insurance Card pay $0? It's not as if tourists are indigent or somehow cannot afford to pay, even a small fee on a sliding scale so that the country health system gets paid for resources used for treatment. I'm not blaming the OP at all, it's not their fault.

http://www.italia.it/en/useful-info/rights-for-tourists/healthcare.html
"Non-EU citizens coming from countries not covered by the agreement are provided with health services that must be paid for in accordance with the relative scale of charges."

How they deal with travel insurance like Travel Guard etc, I don't know. In this case, they didn't seem interested in charging the OP or their insurance anything. Maybe they don't want to deal with the admin burden or maybe any ER visit is a write-off...any other ideas?

Posted by
31050 posts

I too have experienced the medical care in Italy due to a serious leg injury, and that included an ambulance ride, Orthopedic surgery and a week in hospital. I was asked for my Passport by both the ambulance and hospital, and I also gave my medical insurance information to the hospital. The care was excellent and they included a 30 day supply of med's when I left hospital.

At one point I was given a slip of paper which showed the total of my bill, but I was never asked for money when I left hospital. I'm assuming the travel insurance company took care of that? They had local representatives in the area who could deal directly with the hospital.

That's the first time I've ever had to use travel insurance, although I have that every time I travel. They even provided a chauffeur driven Mercedes from the hospital to MXP, which I thought was a nice touch.

In terms of reciprocity for Italian visitors to Canada, there may be some for hospital charges but here in BC visitors are billed for ambulance rides so it's a good idea to have insurance. The charge is quite reasonable compared to other places in North America.

I can't imagine having to pay $1400 for an ER visit.

Posted by
1112 posts

Roberto, you are exactly right. I took down my initial post which described the color rating for seriousness of the health problem (red, yellow, green, blue, white) in determining payment. I had missed the ending which said the freebies for red, yellow, and green only applied to EU citizens and others had to pay. Yet the reality in the ER is clearly different. I guess the health care personnel are not on board with cost recovery.

Posted by
11981 posts

As an Italian citizen but residing outside of the EU, I am not covered by the Italian National Health system, and that I confirmed with the Italian Consulate in SF. Emergency services are covered for Italians who emigrated overseas, only if one communicated to the Italian Consulate prior to traveling S/he is not insured in the country of residency. Otherwise, they have to pay like any other foreigner. Note that even that clause is available to Italian “emigrants”, but is not available to Italian citizens whe never lived in Italy (for example Italians who acquired citizenship overseas through marriage or ius sanguinis). I would need to move back and re establish residency there to become eligible.
I hope if I ever need it while vacationing there, they afford the same freebies to me as they do to you. Apparently hospital staff there has a lot of latitude about who and what to charge. In the hospitals where I work, that doesn’t happen. We may not be able to collect all the time, but everybody gets charged.

Posted by
31050 posts

Roberto,

Hopefully you'll be taking out travel medical insurance for your trips to Italy, just in case you aren't afforded the same benefits.

Posted by
771 posts

I realize this discussion is in the Italy forum, but thought I'd share an experience with the French medical system. Bayeux, 2012, my Mom fell outside the train station and split her lip open, enough to need stitches. The personnel at the station called an ambulance, and she was transported (albeit a pretty short distance) to the hospital, where she got her stitches and we were on our way. The hospital personnel asked if we could come back the following day to pay, which we did. As we sat in front of the accounts receivable person as she toted up our charges, we had American-sized ER costs floating around in our heads, so had the credit card ready to go. When she presented us the bill, we nearly fainted--a whopping €68.

Posted by
135 posts

A friend of mine broke her ankle in Rome. Same deal, went to the ER, x-rays, bone was set, cast put on, they gave her crutches. As she was about to be discharged, she asked about payment. "No charge," she was told. "You're a guest here, you injured yourself on our cobblestones. I know how things work in your country [the U.S.] but we don't charge guests for our services."

Posted by
11981 posts

I see.
Now we know who’s causing runaway deficits in the Italian national health system’s budget: foreign tourists getting a free pass at the taxpayers’ expense.

Posted by
752 posts

Hi Roberto!
For the first time in my life I went three times this month to the ER at Nuovo Regina Margherita in Trastevere. Each time I still get stumped at the question "What's wrong?" that the intake guy asks right away. I'm not for sure but I think the last time I heard that question first up I was a college kid in the nurse's office in the early 1960s.

Anyway I show both my USA passport and Chicago Consulate-issued Italian passport. The ER records only the Italian passport and this last time asked for my local address. I've not been charged for any of the three ER visits. Is there a 65 and over rule about this? Maybe that helps explain at least in part why no charges?

I am charged at the Farmacia. The prescription totaled 61 Euro. I had only 59 Euro on me cause I give a 2 Euro coin to a homeless man and his dog every time I see them in the Metro tunnel at Re di Roma and I had just seen them.

The Farmacia gave me the medicine for 59 Euro. But I don't get a receipt when I pay less than the bill, which locals tell me is common practice.

And I have no national health card.

Posted by
1 posts

Agnes is right. Universal healthcare model is actually very expensive. Italians pay around 43% of their income in taxes and most of them are dedicated to maintaining the national healthcare service.
The service might seem free of charge to tourists but most of the medical services (except family physician and serious medical conditions requiring emergency care) are paid through a co-pay system (called "ticket").
If you are interested there are a few pages in English dedicated to inform people about Italian health care:

http://www.salute.gov.it/imgs/C_17_opuscoliPoster_118_ulterioriallegati_ulterioreallegato_4_alleg.pdf (Ministry of Health)

https://www.doctorsinitaly.com/healthcare-in-italy/ (Association of English Speaking Doctors in Italy).

Cheers,
Silvana

Posted by
11981 posts

It is not true that most of what Italians pay in taxes go to the National Health Service.
In 2016 the State expenditure for the National Health Service was 111 billion euro, out of a total 830 billion euro of total public expenditure. 111/830 is equal to 13.4% of the total budget expenditure.
In terms of total health expenditures, which includes public and private expenditure, Italians spend approximately 150billion euro, or 9% of total GDP. That is half of what Americans spend on health, as a percent of GDP.
The Italian National Health Service is cheap in comparison.

Posted by
93 posts

Without trying to express a political opinion, as a cost accountant I've learned that there are a total of three measures that need to be considered:

  1. Cost
  2. Quality
  3. Speed (sometimes called "cycle time")

Two of the three can usually be reduced at the expense of the third.

Posted by
11697 posts

Too funny, rab. That's exactly what we used to tell marketing/sales when they wanted (at 5:00 PM) creative work done by the next morning...and within budget.

"You can have it cheap, fast or good. Pick two."

Posted by
3307 posts

We ended up in the ER in Italy a few years back for my husband. Thought he was having an appendicitis attack but it turned out to be kidney stones...painful but not life-threatening thank goodness! Once all was said and done it involved an ambulance ride, two physicians, an ultrasound, and pain meds. We didn't pay in the emergency room but did receive a bill when we arrived home. It was so nominal though! Only a couple hundred dollars which we couldn't believe being from the US.

Posted by
27 posts

Haha, Kathy. I worked in marketing and sales and I had to use that with several tough customers as well. Seems it works in many (all?) situations.

Posted by
6235 posts

The service might seem free of charge to tourists but most of the
medical services (except family physician and serious medical
conditions requiring emergency care) are paid through a co-pay system
(called "ticket").

After reading this and other posters' experiences, it's still not clear to me which expenses tourists are actually asked to pay for. If emergency care is exempted, that's probably the most costly type of care category for a system to absorb. It's odd to me that a tourist wouldn't experience any kind of cost-sharing, even a minimal amount. Also, what would a "family physician" do for a tourist (is that the same as a pharmacist)? I would think it would be helpful to know for those folks who purchase medical travel insurance so they can gauge their exposure to different types of risks (and roughly how much they can expect to pay). I've never sought any care overseas so I have zero experience with this.

Posted by
11981 posts

I have worked in health insurance and hospital financial management all my life and what Ms. Zaccarello wrote is nonsense.
What Italians call 'ticket' is nothing but a 'deductible' or 'co-pay' like we have in America, whether we have private commercial insurance or a public insurance like Medicare (which also has copays). Co-pays are imposed by insurers (and also by the Italian SSN, or Servizio Sanitario Nazionale) as a disincentive for overutilization. The copays Italians pay are on average much lower than what Americans pay in copayment, but either way the copay often is just a fraction of the overall cost of the service. For example, a commercial insurer in America typically imposes a co-payment of $150 for the ER. On average a ER bill going to an insurance company, after contractual allowances and discounts, is well over $500 and up just as a start for the simplest cases. I don't get to see a lot of ER bills lower than that. More typically they run into the thousands of $$. Obviously the $150 copay covers only a fraction of the cost, and is there only as a disincentive for subscribers to use the ER unless really necessary.
The Italian SSN introduced copays ('tickets') for ER in 2007. They vary from Region to region, and for some emergencies and some patients are not applied, but typically most regions have it at 25 euro. Italian costs are lower, but even in their case 25 euro represents only a fraction of what an ER service costs.

Regarding the relationship of Cost-Quality-Speed, that is true only in part. There are several dynamics that drive the US healthcare costs up, and are not all related to higher quality or higher speed. In part they are due to the disproportionately higher compensation of healthcare workers in America compared to Italy and other European countries, and healthcare is very labor intensive. The higher compensation is often driven by the shortage of these qualified workers, often determined by the excessive licensing requirements necessary to access those professions. Italy has some of the highest numbers of doctors and nurses per capita in the world, and their schools churn out a higher number of them yearly, therefore their salaries are lower simply as a result of demand and supply. Also, when I compare regulations with my relatives (some of whom are doctors and administrators in the Italian SSN) I note they don't have the stringent staff to patient ratios we are imposed in California, therefore they don't need to be as staffed with RNs as we are.

There are also issues related to excessive use of services ordered by physicians, sometimes unnecessarily. That is due to the different reimbursement schemes existing in the US compared to a National Universal system. The US system, based on a variety of commercial and public insurance payers, give incentive to doctors and hospital to order services in excess of what is needed and to over-invest in high end technology to attract customers. In America doctors or hospitals don't get paid unless they do something to you. In Italy the paymement schemes are based on capitation and hospitals have budgets determined by community needs and population health stats, so they don't have an incentive for you to show up at the doctor's office or at the hospital, on the contrary, they prefer if you stay home (and rather send the doctor to your house). The space here is not enough to explain this complicated matter, but the incentives-disincentives of the payment mechanisms are different, and our current US system incentivizes overutilization of services and over investment in technology, which forces providers to utilize more of it, even if not necessary, simply to recoup the depreciation costs. So the higher cost of the US system is not necessarily related to higher quality, and actually in many measures our outcomes are lower because our services are not as integrated as theirs.

Posted by
15615 posts

NPR had a show the other night how US medical service providers have become almost the sole market for fax machines. Everybody else scans documents and transmits them vie e-mail. Doctors and hospitals, for various reasons, stick to cludgey faxes.

Posted by
5157 posts

Very interesting discussion. So what are European travelers to the US advised to do? Supplemental insurance? Does their national system reimburse them for US medical care? Regardless of cost? I'm imagining taking a foreign relative to the ER in the US and advising them on what to prepare for.

Posted by
792 posts

bottom line Roberto ...if I get injured in Italy, with no traveler insurance and need ER ...what is my cost?

Posted by
11981 posts

European travelers coming to the US should ABSOLUTELY buy travelers' health insurance. The Italian SSN does not reimburse those costs (and neither do the other European systems) simply because there is not a reciprocity agreement like there is among the EU countries for their citizens traveling within Europe.

It's not that without paying hospitals would not take care of those Euro travelers in the ER unless they give the credit card first. They would be taken care of in case of an emergency regardless of ability to pay. A federal law called EMTALA prohibits patient dumping and mandates all hospitals operating a ER to take care of anybody in need, regardless of financial or other status, who shows up to the ER. Failure to comply with EMTALA imposes fines, but above all, may have more disastrous consequences for the hospital, namely being disqualified from participation in government programs like Medicare, Medicaid, etc. Without the revenue stream from government programs an acute hospital cannot possibly survive financially. However after the patient is stabilized, the hospital has the right to request payment. If that is not possible on the spot, patients will receive a bill at home in their country. Hospitals do utilize international collecting agencies (OVAG International, a multinational collection agency based in Switzerland, is the leader in the hospital bills collection field) to go after debtors overseas.

Posted by
27 posts

Jim in VA: I was injured pretty badly in Italy, visited the ER and didn't pay anything. Although I had travel insurance, no one ever asked for it. That's how this whole discussion started, as it was startling for me as a US citizen. I expected a huge bill. Instead, I got great care and no money was ever requested.

Posted by
792 posts

so the key point is ... buy travelers insurance ...right Hope and Roberto?

Posted by
3580 posts

On my first RS tour in 2000 a tour member had a crisis on the first day of the tour. We deposited him and an assistant tour leader at the local ER. Hours later, after a thorough checkup, our tour member was released. There was no charge. He was fine, but probably had a strong reaction to Jet Lag! He did miss the trip to Monet's garden, but didn't seem to feel bad about that.
I always buy travel insurance specifically for Emergency Evacuation expenses.

Posted by
11981 posts

I think it’s a good idea to buy some kind of health insurance protection when traveling overseas. Obviously in Italy, workers of the Italian Servizio Sanitario Nazionale (bless their hearts) have the discretion to treat foreign tourists like residents and charge them the same low copays (or no copays) as Italian residents are charged. That may not be the case elsewhere in Europe or the world. My brother in law had to pay several hundred dollars for ER Care in Mexico (and was reimbursed later by his insurance).

But if you know of any friend or relative coming to the US from overseas, tell them to cover themselves with travelers’ insurance. In our SF Bay Area hospitals we have numerous accounts due from foreign tourists who occasionally end up at the ER (especially in SF) without coverage and OVAG (the international collection vendor employed by our system) goes after those accounts, especially the larger balances. Not fun. Especially considering the ridiculously high charges of ER accounts in the US.