Health insurance coverage for ambulance services: Don’t get taken for a ride
Tamara E. Holmes
If you’ve ever needed to get to a hospital in an ambulance, chances are you weren’t thinking about who would pick up the bill while you were on the gurney. Seeing the bill may leave you feeling sick all over again, though. Why? Your health insurance company may refuse to pay the ambulance tab, leaving you on the hook for perhaps thousands of dollars in out-of-pocket expenses.
Every health insurer has its own rules regarding payment for ambulance services. Typically, a insurer will pay for services considered to be emergencies when using another form of transportation, such as a car, could harm the patient’s health. An insurer also might pay for an air ambulance if speed is critical or if there are obstacles to reaching a hospital by ground.
Sometimes an insurer won’t pay for an ambulance ride or will make only a partial payment because the ambulance operator isn’t part of the insurer’s provider network, says Erin Moaratty, a spokeswoman for the Patient Advocate Foundation, which negotiates with insurers on behalf of patients.
Like doctor’s offices and other health care providers, ambulance operators that are part of an insurer’s network typically agree to a set of negotiated fees. Some ambulance providers refuse to join insurers’ networks because they argue that the established payments are too low.
Municipalities sometimes offer help when a health insurer picks up only part of your ambulance bill. For example, in Washington, D.C., senior citizens don’t have to pay ambulance charges that aren’t covered by Medicare or private insurance.
Also, you can buy insurance to help you handle out-of-pocket ambulance costs. For example, both Nada Insurance, a division of the National Automobile Dealers Association, and Aflac offer accident insurance, which will pick up the tab on some ambulance services not covered by a patient’s main health insurer. The cost typically varies, although it’s much lower than regular health insurance. For example, NADA Insurance charges as much as $9 a month for accident insurance.
When you’re stuck with the bill
But what if you don’t have accident insurance or don’t live someplace like D.C. that partly covers ambulance costs?
The best way consumers can prepare themselves for the cost of ambulance rides is by knowing ahead of time what their health insurers will pay and what they won’t.
But if you find yourself stuck with thousands of dollars in ambulance bills, you can file an appeal with your insurer to challenge a claim denial, Moaratty says. The primary goal of any appeal is to prove to your insurer that the ambulance ride was medically necessary. A physician could provide documentation that the ride was the best mode of transportation. Likewise, proof that the patient needed certain medical equipment or that he or she needed to remain in a reclining position also could bolster the case. An argument also could be made that speed was a factor since an ambulance can get to a hospital faster than another type of vehicle.
Health insurance consumers shouldn’t be afraid to fight a denied claim for ambulance costs. Moaratty says that by challenging a denial, her group has won appeals and even gained bigger reimbursements if a more expensive out-of-network ambulance operator was used.
If an appeal fails, “discuss charity or payment arrangements if insurance coverage is ruled out,” Moaratty says.
How ambulance fees are set
The costs associated with ambulance rides vary, but they can easily reach into the thousands of dollars, depending on the type of medical treatment given along the way. Factors like transportation costs, medical equipment used and salaries paid to ambulance staffers all play a role in the charges you rack up.
Ambulance rates typically are determined by the municipality where the services are provided, says Deborah Hileman, a spokeswoman for American Medical Response (AMR), a private ambulance operator based in Greenwood Village, Colo.
Methods used to calculate the rates vary significantly from city to city, Hileman says. For example, ambulance rides providing basic life support in the City of Chicago cost $725, plus $15 a mile, while advanced life support treatment costs $850, plus $15 a mile. A Chicago patient needing oxygen would pay an additional $25. Likewise, in California’s San Luis Obispo County, the base ambulance rate is $1,947, according to EMS West, a provider of news and information about EMS services.
Keep in mind that there are different types of ambulance operators. In many cities, emergency ambulance services are provided by a local fire department. Other cities hire private ambulance providers, such as AMR, to provide services. Some places use a hybrid: The fire department may be the first responder and provide basic care until an ambulance from a private company arrives. At that point, the private ambulance operator would take the patient to a hospital.
Can I choose the ambulance operator?
According to the American Ambulance Association, more than 15,000 ambulance services and more than 48,000 ambulances are on American streets. The sheer number of different providers creates its own potential problem for consumers. Different health insurers work with their own networks of ambulance providers. If you’re transported by an ambulance that’s not in your network, your insurer may deny your claim.
That wouldn’t be a problem if you could simply pick up the phone and call an ambulance provider that’s in your network. Instead, patients typically call 911, and the type of ambulance that’s dispatched is based on the medical problem. For example, one ambulance may be staffed with emergency medical technicians, who are trained to handle basic life support services such as administering oxygen and CPR. Another may have paramedics, who are trained to provide advanced life support services, such as heart monitoring and IV therapy, the American Ambulance Association says.