When you're calling for an ambulance, chances are good that you won't think to ask for one that's in your health plan's provider network. And in most cases, you wouldn't have much control over who it is anyway. That could leave you with hassles and extra charges for an out-of-network ride.
This spring, Blue Cross Blue Shield of Massachusetts launched a policy aimed at getting more emergency medical services providers to join its network: It began sending checks for out-of-network private ambulance rides directly to plan members rather than to the EMS providers. The move forces these providers to pursue consumers individually for payment — a more complicated process than getting the money straight from BCBS. (Government ambulance services are exempt from the new policy.)
This is another wrinkle in the complicated process of providing and paying for ambulance services. Systems vary widely around the country, as does funding, which may be a mix of tax subsidies, fee-for-service payments and donations. In many places, municipal EMS providers respond to 911 calls, while private companies handle non-emergency transport, such as between hospitals and nursing homes.
For example, in mid-Atlantic urban areas, fire departments and private companies each handle about a third of ambulance transports, with the remainder split among different providers, including municipal services. Emergency dispatchers, often city or county employees, make decisions about what type of personnel to send on an ambulance run depending on the problem described.
In Massachusetts, BCBS says that getting more private EMS providers into its network would reduce costs. "This . . . is really about whether individuals, families and employers should pay 80 to 100 million dollars a year because private out-of-network ambulance companies are allowed to charge rates that are three to five times above what Medicare pays them for the very same service," says Jay McQuaide, senior vice president of corporate communications for BCBS of Massachusetts.
Emergency services professionals counter that some insurers' reimbursement rates are too low to make joining their networks cost-effective. "We try to participate, but sometimes plans come at us with rates that aren't fair," says Michael Gerardi, an emergency physician who is on the board of directors of the American College of Emergency Physicians and who has expertise on reimbursement and billing for emergency care. "They don't respect our costs, our commitment, that we're available 24/7."
In-network reimbursements are sometimes just 50 percent of the charges or a percentage of the Medicare reimbursement rate, says Robert E. O'Connor, chairman of the Department of Emergency Medicine at the University of Virginia School of Medicine. If the EMS company doesn't join the network, reimbursement may not be much improved, he says. "It's often at a rate that they decide unilaterally, and is very low relative to the charge."
In addition to the distance traveled, ambulance bills may vary based on several factors, say experts, including the skills required of the team answering the call and whether the patient needs oxygen or other special supplies.
When insurers and EMS providers bicker over payments, consumers are caught in the middle. So some states have moved to prohibit insurers from sending checks to plan members for out-of-network ambulance services. In at least six states, insurers are required or authorized to reimburse 911 responders directly for ambulance services they provide that are covered by insurance, according to a legislative analysis and Maryland has a law that will take effect in January. Massachusetts lawmakers are also considering a similar measure.
'It Made Me Furious'
For a patient, the only thing worse than being pulled into an insurer-provider tug of war is getting stuck with a pricey bill. But that's what sometimes happens when plan members unwittingly use out-of-network ambulance services.
Just ask Robin Spring. While undergoing chemotherapy for uterine cancer two years ago, she became short of breath and faint at her home in rural Corralitos, Calif. She called her oncologist, who told her to call 911. The ambulance took her to a hospital 20 miles away, where she was admitted with a bowel obstruction. She stayed for 10 days.
The ambulance bill was $2,288. Her insurance policy paid $750 of that total, leaving Spring responsible for the balance of $1,538. When she called her insurer to find out why it hadn't covered more of the bill, she learned that while her plan covered 80 percent of charges for in-network ambulance services, coverage for an out-of-network provider maxed out at $750. And there was a twist, as she later learned: There were no in-network ambulance services in Santa Cruz County, where she lived.