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Taken For A Ride: Ambulances Stick Patients With Surprise Bills as Insurers Balk

| November 28, 2017

ambulance costs surprise bills

Expensive rides. (© FlaglerLive)

One patient got a $3,660 bill for a 4-mile ride. Another was charged $8,460 for a trip from one hospital that could not handle his case to another that could. Still another found herself marooned at an out-of-network hospital, where she’d been taken by ambulance without her consent.

These patients all took ambulances in emergencies and got slammed with unexpected bills. Public outrage has erupted over surprise medical bills — generally out-of-network charges that a patient did not expect or could not control — prompting 21 states to pass laws protecting consumers in some situations. But these laws largely ignore ground ambulance rides, which can leave patients stuck with hundreds or even thousands of dollars in bills, with few options for recourse, finds a Kaiser Health News review of 350 consumer complaints in 32 states.

Patients usually choose to go to the doctor, but they are vulnerable when they call 911 — or get into an ambulance. The dispatcher picks the ambulance crew, which, in turn, often picks the hospital. Moreover, many ambulances are not summoned by patients. Instead, the crew arrives at the scene having heard about an accident on a scanner, or because police or a bystander called 911.

Betsy Imholz, special projects director at the Consumers Union, which has collected over 700 patient stories about surprise medical bills, said at least a quarter concern ambulances.

“It’s a huge problem,” she said.

Forty years ago, most ambulances were free for patients, provided by volunteers or town fire departments using taxpayer money, said Jay Fitch, president of Fitch & Associates, an emergency services consulting firm. Today, ambulances are increasingly run by private companies and venture capital firms. Ambulance providers now often charge by the mile and sometimes for each “service,” like providing oxygen. If the ambulance is staffed by paramedics rather than emergency medical technicians, that will result in a higher charge — even if the patient didn’t need paramedic-level services. Charges range widely from zero to thousands of dollars, depending on billing practices.

The core of the problem is that ambulance and private insurance companies often can’t agree on a fair price, so the ambulance service doesn’t join the insurance network. That leaves patients stuck in the middle with out-of-network charges that are not negotiated, Imholz said. (In Flagler County, where all ambulance service is provided by Flagler County Fire Rescue, revenue from ambulance fees account for almost a fifth of the fire department‘s annual $13.3 million budget, though that revenue has been falling over the past few years.) 

This happens to patients frequently, according to one recent study of over half a million ambulance trips taken by patients with private insurance in 2014. The study found that 26 percent of these trips were billed on an out-of-network basis.

That figure is “quite jarring,” said Loren Adler, associate director for the USC-Brookings Schaeffer Initiative and co-author of recent research on surprise billing.

The KHN review of complaints revealed two common scenarios leaving patients in debt: First, patients get in an ambulance after a 911 call. Second, an ambulance transfers them between hospitals. In both scenarios, patients later learn the fee is much higher because the ambulance was out-of-network, and after their insurer pays what it deems fair, they get a surprise bill for the balance, also known as a “balance bill.”

The Better Business Bureau has received nearly 1,200 consumer complaints about ambulances in the past three years; half were related to billing, and 46 mentioned out-of-network charges, spokeswoman Katherine Hutt said.

While the federal government sets reimbursement rates for patients on Medicare and Medicaid, it does not regulate ambulance fees for patients with private insurance. In the absence of federal rules, those patients are left with a fragmented system in which the cost of a similar ambulance ride can vary widely from town to town. There are about 14,000 ambulance services across the country, run by governments, volunteers, hospitals and private companies, according to the American Ambulance Association.

For a glimpse into the unpredictable, fragmented system, consider the case of Roman Barshay. The 46-year-old software engineer, who lives in Brooklyn, N.Y., was visiting friends in the Boston suburb of Chestnut Hill last November when he took a nasty fall.

Barshay felt a sharp pain in his chest and back and had trouble walking. An ambulance crew responded to a 911 call at the house and drove him 4 miles to Brigham and Women’s Hospital, taking his blood pressure as he lay down in the back. Doctors there determined he had sprained tendons and ligaments and a bruised foot, and released him after about four hours, he said.

After Barshay returned to Brooklyn, he got a bill totaling $3,660 — which is $915 for each mile of the ambulance ride. His insurance had paid nearly half, leaving him to pay the remaining $1,890.50.

“I thought it was a mistake,” Barshay said.

But Fallon Ambulance Service, a private company, was out-of-network for his UnitedHealthcare insurance plan.

“The cost is outrageous,” said Barshay, who reluctantly paid the $1,890.50 after Fallon sent it to a collection agency. If he had known what the ride would cost, he said, he would at least have been able to refuse and “crawl to the hospital myself.”

“You feel horribly to send a patient a bill like that,” said Peter Racicot, senior vice president of Fallon, a family-owned company based outside Boston.

But ambulance companies are “severely underfunded” by Medicare and Medicaid, Racicot said, so Fallon must balance the books by charging higher rates for patients with private insurance.

Racicot said his company has not contracted with Barshay’s insurer because they couldn’t agree on a fair rate. When insurers and ambulance companies can’t agree, he said, “unfortunately, the subscribers wind up in the middle.”

It’s also unrealistic to expect EMTs and paramedics at the scene of an emergency to determine whether the company takes a patient’s insurance, Racicot added.

Ambulance services have to charge enough to subsidize the cost of keeping crews ready around-the-clock even if no calls come in, said Fitch, the ambulance consultant. In a third of the cases where an ambulance crew answers a call, he added, they end up not transporting anyone and the company typically isn’t reimbursed for the trip.

In part, Barshay had bad luck. If the injury had happened just a mile away inside Boston city limits, he could have ridden a city ambulance, which would have charged $1,490, according to Boston EMS, a sum that his insurer probably would have covered in full.

Very few states have laws limiting ambulance charges, and most state laws that protect patients from surprise billing do not apply to ground ambulance rides, according to attorney Brian Werfel, consultant to the American Ambulance Association. And none of the state surprise-billing protections applies to people with self-funded employer-sponsored health insurance plans, which are regulated only by federal law.  That’s a huge exception: 61 percent of privately insured employees are covered by self-funded employer-sponsored plans.

Some towns that hire private companies to respond to 911 calls may regulate fees or prohibit balance billing, Werfel said, but each locality is different.

Insurance companies try to protect patients from balance billing by negotiating rates with ambulance companies, said Cathryn Donaldson, spokeswoman for America’s Health Insurance Plans. But “some ambulance companies have been resistant to join plan networks” when insurance companies offer Medicare-based rates, she said.

Medicare rates vary widely by geographic area. On average, ambulance services make a small profit on Medicare payments, according to a report by the U.S. Government Accountability Office. If a patient uses a basic life support ambulance in an emergency, in an urban area, for instance, Medicare payments range from $324 to $453, plus $7.29 per mile. Medicaid rates tend to be significantly lower.

There’s evidence of “waste and fraud” in the ambulance industry, Donaldson added, citing a 2015 study from the Office of Inspector General at the U.S. Department of Health and Human Services. The report concluded Medicare paid over $50 million in improper ambulance bills, including for supposedly emergency-level transport that ended at a nursing home, not a hospital. One in 5 ambulance services had “questionable billing practices,” the report found.

Most complaints reviewed by Kaiser Health News did not appear to involve fraudulent charges. Instead, patients got caught in a system in which ambulance services can legally charge thousands of dollars for a single trip — even when the trip starts at an in-network hospital.

That’s what happened to Devin Hall, a 67-year-old retired postal inspector in Northern California. While he faces stage 3 prostate cancer, Hall is also fighting a $7,109.70 out-of-network ambulance bill from American Medical Response, the nation’s largest ambulance provider.

On Dec. 27, 2016, Hall went to a local hospital with rectal bleeding. Since the hospital didn’t have the right specialist to treat his symptoms, it arranged for an ambulance ride to another hospital about 20 miles away. Even though the hospital was in-network, the ambulance was not.

Hall was stunned to see that AMR billed $8,460 for the trip. His federal health plan, the Special Agents Mutual Benefit Association, paid $1,350.30 and held Hall responsible for $727.08, records show. The health plan paid that amount because AMR’s charges exceeded its Medicare-based fee schedule, according to its explanation of benefits. But AMR turned over his case to a debt collector, Credence Resource Management, which sent an Aug. 25 notice seeking the full balance of $7,109.70.

“These charges are exorbitant — I just don’t think what AMR is doing is right,” said Hall, noting that he had intentionally sought treatment at an in-network hospital.

He has spent months on the phone calling the hospital, his insurer and AMR trying to resolve the matter. Given his prognosis, he worries about leaving his wife with a legal fight and a lien on their Brentwood, Calif., house for a debt they shouldn’t owe.

After being contacted by Kaiser Health News, AMR said it has pulled Hall’s case from collections while it reviews the billing. After further review, company spokesman Jason Sorrick said the charges were warranted because it was a “critical care transport, which requires a specialized nurse and equipment on board.”

Sorrick faulted Hall’s health plan for underpaying, and said Hall could receive a discount if he qualifies for AMR’s “compassionate care program” based on his financial and medical situation.

“In this case, it appears the patient’s insurance company simply made up a price they wanted to pay,” Sorrick said.

In July, a California law went into effect that protects consumers from surprise medical bills from out-of-network providers, including some ambulance transport between hospitals. But Hall’s case occurred before that, and the state law doesn’t apply to his federal insurance plan.

The consumer complaints reviewed by Kaiser Health News reveal a wide variety of ways that patients are left fighting big bills:

  • An older patient in California said debt collectors called incessantly, including on Sunday mornings and at night, demanding an extra $500 on top of the $1,000 that his insurance had paid for an ambulance trip.
  • Two ambulance services responded to a New Jersey man’s 911 call when he felt burning in his chest. One charged him $2,100 for treating him on the scene for less than 30 minutes — even though he never rode in that company’s ambulance.
  • A woman who rolled over in her Jeep in Texas received a bill for a $26,400 “trauma activation fee” — a fee triggered when the ambulance service called ahead to the emergency department to assemble a trauma team. The woman, who did not require trauma care, fought the hospital to get the fee waived.

In other cases, patients face financial hardship when ambulances take them to out-of-network hospitals. Patients don’t always have a choice in where to seek care; that’s up to the ambulance crew and depends on the protocols written by the medical director of each ambulance service, said Werfel, the ambulance association consultant.

Sarah Wilson, a 36-year-old microbiologist, had a seizure at her grandmother’s house in rural Ohio on March 18, 2016, the day after having hip surgery at Akron City Hospital. When her husband called 911, the private ambulance crew that responded refused to take her back to Akron City Hospital, instead driving her to an out-of-network hospital that was 22 miles closer. Wilson refused care because the hospital was out-of-network, she said. Wilson wanted to leave. But “I was literally trapped in my stretcher,” without the crutches she needed to walk, she said. Her husband, who had followed by car, wasn’t allowed to see her right away. She ended up leaving against medical advice at 4 a.m. She landed in collections for a $202 hospital bill for a medical examination, which damaged her credit score, she said.

Ken Joseph, chief paramedic of Emergency Medical Transport Inc., the private ambulance company that transported Wilson, said company protocol is to take patients to the “closest appropriate facility.” Serving a wide rural area with just two ambulances, the company has to get each ambulance back to its station quickly so it can be ready for the next call, he said.

Patients like Wilson are often left to battle these bills alone, because there are no federal protections for patients with private insurance.

Rep. Lloyd Doggett (D-Texas), who has been pushing for federal legislationprotecting patients from surprise hospital bills, said in a statement that he supports doing the same for ambulance bills.

Meanwhile, patients do have the right to refuse an ambulance ride, as long as they are over 18 and mentally capable.

“You could just take an Uber,” said Adler, of the Schaeffer Initiative. But if you need an ambulance, there’s little recourse to avoid surprise bills, he said, “other than yelling at the insurance company after the fact, or yelling at the ambulance company.”

–Melissa Bailey, Kaiser Health News, with KHN correspondent Chad Terhune


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22 Responses for “Taken For A Ride: Ambulances Stick Patients With Surprise Bills as Insurers Balk”

  1. Will Awdry says:

    Ambulance rides were never ‘free’ as this article states. Those Fire Departments and Ambulance Squads are supported as a public service by your taxes.
    This article ignores the fact that in most states ambulances (public and private) are staffed by highly trained and continuously certified EMTs and paramedics.
    911 services in almost every state prohibit ambulance crews from ‘listening on a scanner’ and choosing to respond. The fact is that many municipalities that can’t find volunteers hire private ambulance companies to respond to 911 calls.
    When a person is loaded in an ambulance it is because staff believes that there was ‘medical necessity’ to get that person to the closest location were medical aid can be rendered.
    As the article points out (in the second to last sentence) any adult can decline medical treatment (and thus a ride in the ambulance (and the associated cost).

  2. Robert Lewis says:

    I thought my taxes paid for the ambulance? Why does my insurance pay?
    What exactly am I paying for? Why does it cost so much?

  3. Concerned Observer says:

    Thank you. This is all great information should I travel to California, Ohio or one of the unnamed locations, but what can we expect here in Flagler County? A little further investigation uncovered that Florida IS one of 21 states with “Comprehensive” regulations, but not much beyond that. I would expect transportation via Fire Flight would be more expensive, and rightfully so. How much more? What if Fire Flight in unavailable and a helicopter is called from neighboring Volusia or St Johns county? Does Medicare cover emergency ambulance or helicopter transportation? Any help??

  4. County medic says:

    There is a serious problem with the title of the article. Ambulances do not stick patients with high bills. Politicians and insurance companies stick patients with high bills.

    The paramedics on those ambulances often encounter patients that desperately need to be treated on the way to the hospital but refuse to go because their afraid of the bill. We do our best to try to convince them to go, but many times are unsuccessful.

    Ambulances and paramedics do not bill patients. Politicians and insurance companies do.

  5. Wishful thinking says:

    Thieves without guns.. scary. Didn’t know what a racket emergency transport has become.. thank you Flagler live for exposing the health care growing mob

  6. Anonymous says:

    Flagler County is guilty of price gouging in this area too. They are also making money hand over fist by transporting patients to other counties when we the people own the vehicles and pay the salaries of those who drive them. Flagler County also gouges with the use of the county helicopter when it has to urgently get a patient to a hospital quickly to save a life when we the people bought the helicopter, pay the gas insurance etc., and pay the operator. They come up with creative ways to bring in revenue to support their madness spending . It’s like monkey see monkey do…once someone somewhere does something and gets away with it, all counties copy cat whether it is legal or morally right or not. Laws need to be made to protect the people and the sick. It is shameful that sick people and a lot of elderly people are being taken advantage of. This is no different than any other kind of scam. When we experience such occurrences in our county that is when we need to wake up and elect some new blood….lets start in 2018.

  7. about time says:

    Finally! I’m glad they are billing them bc most people thinks it’s a free ride bc they pay taxes and take an ambulance for constipation or flu like symptoms when they can drive!! And the people that really need an ambulance ie, stroke, , cardiac arrest, can’t bc they are tied up w these rediculous claims of “emergencies”. I’ve worked in the medical field for years and and have seen this over and over. Or they don’t want to wait in the waiting room, thinking that coming in by ambulance will gaurantee them a room right away. NO! It doesn’t. I’ve always thought calling an ambulance was life or death situation, until I moved to Florida. And everyone calls them, stub toe or cold symptoms. Really. About time.

  8. r&r says:

    To have been the user of this facility, it’s a great service and the people are VERY professional and if your insurance doesn’t pay for it, it’s time to get a new insurance co. If they take you to the ER at Flagler Hospital you go to the head of the line as far as getting treated. If you’re a walk in regardless of your need you will wait for HOURS before you get treated.

  9. Zuzanna says:

    Not so sure abou “very professional”. A few years back I had a heart attack although I didn’t know it at the time. When the ambulance got to my house they said it was up to me if I wanted to go with them or have my husband drive me. I made them take me and thankfully I was to the hospital in less than 5 minutes. Within a half hour I was in surgery with a 99% blocked artery. Thank God I listened to my gut and made them take me.

  10. Paramedic says:

    @r&r only patients will conditions that meet immediate treatment will be taken to “the front of the line” when a ER bed is not available. Patients who do not meet any criteria for anything will be placed in a bed, if it is available, or moved to triage where everyone else is waiting. Hope this helps.

  11. Pogo says:

    @You’re next

    We live in a country run by white collar criminals. Do something about that and a lot of problems will be solved.

  12. Concerned Citizen says:

    As a former Fire Fighter/EMT I agree with County Medic. This article is misleading and would have you believe the guys and gals working the rescues are instantly charging your credit cards for a transport.

    Paperwork for a medical transport at least in Flagler is submitted to the county. A county accountant handles the billing and issues the final bill. You can refuse transport. And often a lot do. The Paramedics and Fire Fighters just don’t tie you down on the stretcher and kidnap you.

    Our Paramedics here are even trained to assess Trauma and determine whether Fire Flight or a higher level of trauma care is needed.

    Further more in Flagler County Fire Departments are assigned a rescue unit, These Fire Departments work zones. When you have an (MVA) Motor Vehicle Accident or a medical it’s usually called into dispatch. Dispatch then looks at the map and tones out the nearest unit. Our fire rescue folks don’t just lounge around the house listening to a scanner go off LOL.

    Not sure what Flagler Live has against Paramedics and the Rescue service but this is sure a biased article. I find the tone of this article interesting after Paramedics were just recognized with a life saving award.

    • FlaglerLive says:

      Concerned Citizen, only someone who started reading FlaglerLive the moment this particular story went up, ignoring the past seven and a half years, would make as preposterous a suggestion as your last paragraph’s. Not sure where you get the notion from the article that rescuers are swiping credit cards either: when making charges against an article, it’d be helpful if the person making the charge wasn’t using the same sort of hyperbole or bias for which the article is blamed. That said, rescue services are no more sacred cows than any other public or private sector institution. This particular and excellent article from our partners at KHN is a broad look at an issue that reverberates across jurisdictions and is informative in its own right even if county ambulance services’ accounting practices are as saintly as you presume. (Incidentally, we contacted Don Petito, the county fire chief, 24 hours before this article went up to let him know that it was lined up for publication and hear what perspectives he might provide locally. Unusually for Petito, he did not return the call.)

  13. Jennifer says:

    I have a brother who was in an accident that was transported by ambulance 3 miles and charged 2,000 then had to be flown to Halifax in Daytona and was charged 7000. He was unconscious and not responsive and obviously had to do what was best for his survival but out of network for his insurance. Where do they think people who are injured and clearly unable to work will come up with that kind of money upfront?

  14. tim thoms says:

    simply dont pay them..they cant get blood from a rock and there is no debtors prison..toss the bills in the trash and know you had no other choice!!!

  15. woody says:

    How does the person w/no medical insurance,rents pay for life flight?They don’t.

  16. Jean says:

    Maybe they should handle this like they did the tow companies. Set standard rates.

  17. palmcoaster says:

    I know here in Palm Coast about 16 years ago a suffering a heart attack a friend was transported by his Florida Health Care Insurance doctors orders to Flagler Hospital form PC Parkway’s doctors office while the friend that drove him to the doctor followed the ambulance…He received his insurance premium deductible bill for just the ambulance ride $370 and was the deductible God knows how much was the total charge. He almost had another heart attack after his heart surgery while looking at his bills… I don’t believe that Flaglerlive is attacking any of our county EMT’s, but to the contrary the site is alerting us all, of the reality of the ambulance business who’s revenue I wonder how is accounted in our county, by Coffey’s administration. We educated taxpayers know well the great job and honesty our EMT’s in their majority excel…is the greedy government administrators of the service preying into the victims with total green light from our elected one’s.
    And yes I believe in our taxes we pay in every budget year, ambulance and helicopters services that are funded, so then why the gouging? Just because we never raise the issue as for our government administrators and our elected yeser’s, we are to “shut up and pay” and Petito’s attitude confirms it! Maybe is time to have some community leadership to address these abuses. Thank you Flaglerlive.

  18. palmcoaster says:

    Concerned, you are wrong because no one is attacking our EMT’s paramedics of which many excel…and the injured own their survival. What is being questioned is the gouging prices to injured taxpayers when transport by ambulance or helicopter is required given the gravity of their injuries or sickness….that get victimized by these administrators billing them again, after we all sustain both services with the taxes we pay.

  19. Anonymous says:

    We are paying again for what we already paid for. The ambulance, drivers, insurance, uniforms and all are paid with our tax dollars. It is time for new commissions and for Coffey to go. We need people who don’t use and abuse us. Petito is a snake and a member of Coffey and company as is his wife Heidi who together receive nearly $200k of our tax dollars. We should be charged actual costs.

  20. Nancy N. says:

    palmcoaster – if you look at the budget breakdown – there’s about 10 million for fire/rescue. 75% of it comes from the general fund and 25% of it comes from “other sources”, which are listed as being things like ambulance fees and fire inspection fees. So yes technically ambulance service is a government budget item but the funding for it isn’t coming out of tax dollars, it’s being paid for out of fees levied on users and paid to the government. Many government services run like that – for instance, our city trash and water service.

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