Every year, unnecessary Emergency Department visits, or ED visits cost US healthcare payers $32 billion, with $8.3 billion of that attributed to mental health alone. For self-insured groups, these ED visits inflate claims and signal deeper systemic issues such as gaps in access, fragmented care, and unmet member needs.

What makes an ED visit “avoidable”?

“I would classify unnecessary or avoidable ED visits as encounters that could have been safely managed in lower acuity settings,” explains Julia Beene, BSN, RN, Manager of Case Management at Telligen. “If a member has timely access to a primary care facility or behavioral health services, virtual care or after hours, they can utilize those services instead of the costly ED visit.”

These visits are symptoms of a larger problem: reactive care instead of proactive coordination. When members lack access or don’t know where to turn, the ED becomes the default, not the safety net it was designed to be.

“We’re partnering with members directly to create and facilitate relationships with them to make sure that they are having relationships with their primary care provider and utilizing lower acuity settings when appropriate,” Beene notes.

The goal is simple: prevent costly utilization before it happens by addressing root causes, not just symptoms. Which means:

Understanding the why behind frequent visits (e.g. transportation barriers, lack of primary care access, unmanaged chronic conditions)
Connecting members with appropriate resources and providers
Leveraging claims-based data through utilization management services for early identification and intervention

The true costs of ED overutilization & what self-insured employers need to know

Self-insured employers bear the direct cost of every claim. Unlike fully-insured plans where premiums are fixed, self-insured groups experience immediate financial impact from high-cost utilization like avoidable ED visits.

Case Management services have been shown to reduce ER visits by 49% according to an article in The National Library of Medicine – a reduction that translates directly to better health outcomes and bottom-line savings.

Here’s the data according to UnitedHealth Group. Consider the math:

One avoidable ED visit: ~$2,000
Ten employees with chronic conditions making 3 unnecessary ED visits per year: $60,000
Add in workplace stagnation, follow-up care, and downstream complications: easily $100,000+

Now scale that across a workforce of 500, 1,000, or 5,000 employees. Adding on, ED visits are the most expensive site of care, but the costs go deeper than the initial claim:

According to United Healthcare direct costs related to ED visits average $2,032 average cost per visit to ED
Downstream costs (avoidable complications from lack of care continuity, long-term condition progression when issues aren’t proactively managed)
Hidden costs (member dissatisfaction, lost productivity from extended ED wait times, provider burnout and ED overcrowding)

“Unnecessary ED visits create a dual cost burden, the excessive direct claims spend and downstream costs from poor follow-up, redundant testing, and avoidable complications all compound to make this a very expensive problem,” Beene explains.

“For someone getting insurance through your employer, you might think, ‘What’s the harm in going to the ED?’ But that has a long-term systemic effect on healthcare,” Beene notes. “It does affect you eventually. Everything we do affects everybody. Your premium will eventually go up because with rising healthcare costs, if everyone’s using the ED and the plans are having more expensive healthcare costs, it will eventually trickle down to the member themselves.

And it’s not just about dollars. It’s about quality of life.

“This isn’t just about saving money,” Beene emphasizes. “It’s really impacting people’s lives for the better and helping them live the healthiest life they can.”

Focusing on proactive, human-centered care

The key to reducing avoidable ED visits is early intervention, personalized support, and meeting members where they are.

“This isn’t about reducing ED use,” Beene emphasizes. “EDs save lives. They’re not designed to fill in the gaps of access or navigation or behavioral healthcare. When individuals are engaged earlier and they’re supported through strong primary care relationships and a case manager or health coach is helping guide them to the right level of care, the emergency department then becomes what it’s intended to be: a safety net, not a default.”

A case manager can fill in the gaps needed to stop unnecessary emergency department visits. Consider a family whose young child kept presenting to the ED with upper respiratory issues. Antibiotics were prescribed, nebulizers were given, but the cycle continued until a case manager asked the right question: What’s happening at home that could be causing symptoms?

They discovered mold in the house. Once the root cause was addressed, the ED visits stopped. The family got their child’s health back, avoided thousands in unnecessary medical costs, and improved their quality of life.

“I think it’s easy when you don’t know the whole picture to assume.. if someone hasn’t filled their diabetic medications, oh, they’re non-compliant,” Beene notes. “But that may not be the issue. They may not have transportation to get to the medications. They may have health literacy barriers where they’re having issues reading the materials they need to fill out in order to get mail delivery meds. Really putting your detective hat on and trying to figure out what the issues are and addressing them quickly is what we’re skilled at doing.”

Some self-insured employers might look at case management as an expense. But Beene sees it differently: “It’s an investment.”

The ROI is clear: Early intervention reduces costs, improves outcomes, and supports a healthier, more engaged workforce.

Final thoughts

“It’s planting that acorn and waiting for the tree to grow,” Beene reflects. “You’re putting systems in place that help members better manage their health, so they have a better quality of life and aren’t incurring costs that affect everyone.”

The investment in proactive, human-centered care pays dividends, not just in reduced claims costs, but in healthier, more engaged employees who feel supported and valued.

While emergency departments are critical for saving lives, they can’t fill the gaps left by non-proactive care. Preventive actions can catch root causes that fall through the cracks and stop minor health problems from becoming emergencies.

To speak with a Telligen Health and Well-Being expert about how case management solutions can help your organization reduce unnecessary ED visits, please visit: https://www.telligen.com/contact-an-expert-hwb/