Who pays for the ambulance?

After an outpatient procedure last summer, Sidney Fallender was expecting to go straight home. But when two nurses tried to get the 93-year-old Sherman Oaks resident on his feet, they discovered he was unable to walk on his own.

“The doctor told her assistant to call the paramedics,� Fallender recalled. He was taken to Cedars-Sinai Medical Center by ambulance, less than a mile from his doctor’s office, for possible emergency surgery.

“A couple of weeks later I got a bill for the ambulance service in the amount of almost $1,000,� he says. Medicare denied his claim on the grounds that it wasn’t medically necessary, and the ambulance company sought payment directly from him.

Fallender wondered why he owed anything at all for his ride to the hospital. “I am a property-tax payer. I was picked up by a Fire Department ambulance,� he says.

In Southern California, it’s a common misconception that ambulance transportation is a free public service, says Cathy Chidester, director of the Los Angeles County Emergency Medical Services Agency. “Though people think that their tax dollar pays for the paramedic service, it really doesn’t,� she says. “It pays for fire service.�

The operation and financing of ambulance services are complicated and vary widely throughout the country. In Los Angeles County, the Fire Department contracts with ambulance companies to handle emergency transports. The city of Los Angeles handles its own transport and uses its own employees, Chidester says.

Elsewhere around the country, ambulance services are operated by any mix of volunteers, ambulance companies, municipal EMS providers or fire departments.

“If you’ve seen one EMS service you’ve seen one EMS service — because no two are alike,� says Dr. Robert O’Connor, board member of the American College of Emergency Physicians and chair of emergency medicine at the University of Virginia at Charlottesville.

The costs of ambulance services vary widely too. According to a 2012 report by the U.S. Government Accountability Office, an ambulance ride can range from $224 to $2,204 per transport for Medicare beneficiaries. In Los Angeles, charges average about $1,200.

You can’t predict when you’ll need an ambulance, but a little education about how services operate in your area, what insurance policies cover, and common errors in billing can go a long way toward avoiding sticker shock.

Know what insurance covers. Both Medicare and private insurance generally cover the cost of ambulance rides, but they rely on medical necessity when determining reimbursement.

Ambulance trips are considered medically necessary in cases of a sudden emergency or when your health is in serious danger and time is crucial. An ambulance may also be considered a necessary service in non-emergency situations, such as when a patient needs to be moved from one hospital to another.

In Los Angeles and in many parts of the country, emergency ambulance services — those that show up following a call to 911 — don’t hold contracts with insurance companies, so there’s no point worrying about whether you’re being picked up by an in-network provider.

But experts say that if you’re being moved from home to a medical facility or between facilities for treatment, you can reduce out-of-pocket costs by asking in advance whether the ambulance service participates with your health plan.

Confirm that your ride was properly billed. When ambulance services seek payment from insurance companies, they file claims using code numbers to indicate the service they provided. Fallender’s case was clearly an emergency, but his claim was denied, he later learned, because it was billed improperly by the ambulance company when it submitted the bill to Medicare.

That has become a trend in the last 18 months to two years, particularly for Medicare recipients, says Bridget Homer, an attorney with the Center for Health Care Rights in Los Angeles.

“We’re getting tons of calls from people getting ambulance denials,� she says. Ambulance companies are using a code “that indicates it’s not for emergency services, and they’re automatically denied.�

Appeal charges. Consumers can appeal to ambulance companies when bills seem high or improper. All of the ambulance companies contracted for 911 services in Los Angeles County have a patient advocate or billing person available to help.

Homer says it’s worth calling the ambulance company to ask that the bill be coded properly and resubmitted when that’s the reason for payment delays. But she cautions that her organization, which advocates for consumer healthcare rights, has faced some roadblocks.

It’s sometimes difficult getting in touch with someone who will resubmit the claim, resulting in some bills being sent to collections, she says. “People going through the appeals process are having their credit ruined in the end just to have it approved by Medicare.�

When consumers don’t have luck with the ambulance companies directly, Chidester, the county EMS official, says their cases are sometimes referred to her office for resolution.

Experts say consumers facing high bills can also enlist the help of medical billing advocates to negotiate a better price. Medicare denial letters should include the number of an organization where they can get help filing an appeal.

After an involved effort to correct the billing mistake with no luck, Fallender got help from a consumer advocacy organization. “They were extraordinarily helpful,� he says. “The appeal was settled in my favor.�

Resources

Information/help with ambulance services: Los Angeles County Emergency Medical Services Agency at ems.dhs.lacounty.gov or Orange County Emergency Medical Services at healthdisasteroc.org/ems

Help fighting bills: Patient Advocate Foundation offers help appealing medical charges at https://www.patientadvocate.org.

Medicare help: contact Medicare and advocacy organization California Health Advocates at cahealthadvocates.org and the consumer advocacy nonprofit Center for Health Care Rights in Los Angeles at lawhelpca.org

Zamosky writes about healthcare and health insurance.

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