Those ambulance and FireFlight rides to the hospital aren’t free: Flagler County Fire Rescue bills those transported through a third party. About 60 percent of those transported pay. For many reasons, not least among them the lack of insurance or sufficient insurance, the rest don’t. It is one of the many shards of the country’s broken healthcare system.
Since 2018, the county has accrued on average $1.7 million a year in what the county considers to be uncollected bills, or $10.3 million through February 2024. It’s happened for years, if not quite by those amounts. For years, the County Commission has periodically written off the loss, as hospitals and other providers do with their own uncollected payments. The last write-off was for $6.4 million.
The large figure is not without a deceptive caveat. Not all those bills the county considers “uncollected” are, in fact, uncollected. The majority are not.
Bills through Medicaid or Medicare, the government health insurance plans, are paid, but at rates set by Medicaid and Medicare. The county doesn’t bill at those rates. It bills higher–and lumps the different into its unpaid balance pot, which deceptively raises the amount owed the county.
“That’s a large portion of this,” Flagler County Fire Chief Michael Tucker told the commission.
In effect, a large portion of the amount the county is writing off is a county construct that partly veils the fact that the county did get paid for those Medicaid and Medicare transports, in a county where nearly a third of the population is on Medicare. Still: the discussion the county commissioners fixed on took little account of Tucker’s caveat and addressed the $10 million as if it were an outright loss that theoretically could have been collected.
County commissioners were required to go through the formality of approving the write-off on Monday. They did so for the $10.3 million uncollected since 2018, but not before Commissioner Leann Pennington asked: “Is there some sort of plan to resolve this dilemma going forward?”
Though it’s not a written policy, the county had previously opted not to throw the unpaid bills to a collection agency. Doing so might have discouraged residents from calling 911 in emergencies for fear of the eventual bill–as a quarter of Americans still don’t over those same fears, according to a 2024 YouGov survey.
“I would like to make some kind of motion to not allow this to happen again,” Commissioner Pam Richardson said. “If there’s somebody in default and we need to have some kind of process in which we can go ahead and attempt for, whether we hire an outside collection agency or whatever we need to do. This is absurd.” Richardson’s motion, if it was one–none of the other commissioners seemed to take it as one–did not get a second.
This year’s amount is large, said John Brower, the county’s director of financial services, due to a data breach at Change Health Care, the UnitedHealth-affiliated company that provides billing for the county. The company, the largest such clearinghouse in the country, was not able to provide billing after February 21, 2024, according to the county (though the write-off amount predates February 2024, and Brower spoke before Tucker revealed the Medicaid-Medicare caveat).
The breach wasn’t a minor issue. “The February cyberattack interrupted operations for thousands of doctors’ office, hospitals, and pharmacies,” the New Hampshire Department of Justice reported at the time. “It also resulted in Americans’ sensitive health and personal data being leaked onto the dark web – a hidden portion of the internet where cyber criminals buy, sell, and track personal information. Although the actual number and identity of affected patients are currently unknown, Change Healthcare has publicly stated that the data breach could impact up to 1/3 of all Americans. This was an unprecedented data breach.”
A ransomware group reportedly stole 6 terabytes of data, or 6,000 gigabytes. It isn’t unusual for computers to have a terabyte of storage. Google’s cloud storage offers from 2 to 10 terabytes of space to individual customers and companies.
In Flagler County, “We were essentially shut down billing for close to six months,” Tucker said.
The county switched to Digital EMS Billing. That company is charging “double” what Change Health Care used to charge, Brower said. “We’re always going to have uncollectibles, nothing close to this. That’s the expectation,” he said. “Their collections, their process, is a lot better than Change Healthcare’s was.”
“So we lost funding because they had had, what, like a cyber attack, data breach,” Pennington said, “and there’s no accountability on their part to pay us for uncollectibles because of what occurred to them?” Brower said the county is “small potatoes in their world,” and if there is to be a reimbursement, it won’t happen for years. That surprised Pennington, given the enormous amount of write-offs.
County Attorney Michael Rodriguez didn’t know the details of the issue or whether a class-action suit had been filed against Change Health Care. “I had a similar instance with a same ambulance billing provider, one of my former jurisdictions, where we did file a lawsuit,” he said. “There were some impropriety concerns. We ended up having to settle the matter just simply to get back our data.”
Commissioner Kim Carney suggested that the county make its adjustments annually. Commissioners agreed to have “insight into other directions,” as Commission Chair Andy Dance said. What those directions will be is unclear. Tucker reminded the commissioners that the issue underscores the fact that ambulance billing is not a money-maker.
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