With ambulance rides being one of the most expensive modes of transport, Medicare has strict medical necessity guidelines to prevent overuse of this benefit. If Medicare has reason to doubt medical necessity for ambulance transport, Medicare will often deny payment of the claim. While these strict guidelines are understandable, advocates across the state have seen a rise in denied payment of beneficiaries’ ambulance services, even when medical necessity is seemingly a given.
One problem is the billing codes submitted by the ambulance transport company. If the ambulance company doesn’t submit the proper codes that denote medical necessity, Medicare will automatically deny a claim and then it is up to the beneficiary to file an appeal. Also, American Medical Response (AMR), one of the primary ambulance transport service providers in California, has a policy that requires the beneficiary to pay the bill or set up a payment plan within 30 days if Medicare denies payment. If a beneficiary fails to pay within 30 days, AMR forwards the bill to a collection agency. The 30 days is not enough time, especially if a beneficiary has been in the hospital and/or rehab, for the beneficiary to find out about Medicare’s denied payment, file an appeal and hear the result of their appeal. Thus, many beneficiaries have had to pay and file an appeal at the same time, before Medicare decides if the denial was correct.
Sample ambulance appeal case
This point was precisely demonstrated in a recent ambulance appeal case involving a 70-year-old San Franciscan woman. Ms. B was visiting an elderly friend when she slipped and fell on her knee in the bathroom. The next day she awoke in extreme pain, unable to put any weight on her leg, and certainly unable to climb down the flight of 13 stairs. She feared having another fall and potentially injuring her other leg and/or intensifying the injury she already had. As her doctor explained in a subsequent letter claiming medical necessity for the ambulance transport, Ms. B has hypertension, and had suffered from a mild heart attack and a fracture in her femur the year before, all adding to the complication of her situation.
The morning after her fall, Ms. B called an ambulance and she was subsequently admitted into the hospital, bed-confined for 3 days for a right tibial plateau fracture, and then transferred to a skilled nursing facility for 30 days of rehab. It wasn’t until Ms. B finally returned home after more than a month of continuous medical care that she found out that Medicare had denied payment for her ambulance transport, and AMR was demanding immediate payment or her claim of $1,265.02 would go to collections. Fearing bad credit, Ms. B began making monthly payments. At the same time, she contacted the San Francisco County Health Insurance Counseling and Advocacy Program (HICAP) for assistance in filing an appeal.
She worked with HICAP to include substantial evidence documenting medical necessity in her appeal letter and had every reason to believe Medicare would reverse its decision.
A new remedy
To remedy such situations like Ms. B’s, two Medicare advocates in Santa Cruz County, HICAP Program Manager, Debbie Reed, and HICAP Volunteer Counselor, Evelyn Taylor set up a meeting with AMR to discuss possible solutions and also arranged for them to speak at the Spring training conference for HICAP Program Managers in Pasadena, California. The meeting was a success and as a result, HICAP Program Managers and their volunteer HICAP Counselors have a new cooperative agreement with AMR. HICAP advocates now have a specific contact person at AMR to call regarding ambulance billing appeals cases. If they call this AMR rep and state that they are working with a beneficiary to appeal/resolve their ambulance trip directly with Medicare, AMR will now automatically put the beneficiary’s account on hold for 90 days; this is three times as long as the previously noted 30-day policy. This will prevent the beneficiary’s claim from going to a collection agency while an appeal is filed.
Post AMR-HICAP agreement successes
Once the agreement went into effect on April 24, 2012, Ray Jones, one of the San Francisco HICAP Counselors working on Ms. B’s case, immediately called AMR, got her case put on hold and stopped her monthly payments for the ambulance bill. She was the first beneficiary to benefit from this new agreement. Ms. B subsequently got word that she won her appeal, and Medicare approved payment for her ambulance transport.
In addition, Santa Cruz county HICAP Counselor, Evelyn Taylor currently has six 90-day holds on beneficiary claims with AMR and reports the new system is working smoothly.
This new agreement is a big win for beneficiaries. It will give people time to resolve ambulance claims without the added burden and stress of making monthly payments or having their bill go to collections. The collaboration among agencies, providers and advocates illustrate how effective communication can open doors to win/win solutions for all involved.
- Medicare’s Coverage of Ambulance Services (PDF)
- Health Insurance Counseling and Advocacy Program (HICAP) – counseling and advocacy on Medicare related questions, including ambulance coverage and/or appeals questions
- Senior Medicare Patrol – education and resources on Medicare fraud protection, detection and prevention