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 in a beneficiary’s 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 we’ve seen is that often the billing codes submitted by the ambulance transport company determines whether a beneficiary’s transport meets the medical necessity requirements. If the ambulance company doesn’t submit the proper codes that denote medical necessity, Medicare will often 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 had a policy that if Medicare denies an ambulance service, the beneficiary must pay the bill, or set up a payment plan within 30 days; otherwise, their bill goes to a collection agency. This 30-day policy is hardly enough time, especially if a beneficiary has been in the hospital and/or rehab, for s/he to find out about Medicare’s denied payment and file an appeal.
To remedy this situation, two Medicare advocates in Santa Cruz County, Health Insurance Counseling and Advocacy Program (HICAP) Program Manager, Debbie Reed, and Senior Medicare Patrol (SMP) Liaison, Evelyn Taylor set up a meeting with AMR and also arranged for them to speak at our recent biannual Medicare training conference in Pasadena, California. The meetings were a success and as a result, HICAP Program Managers and their volunteer counselors have a specific contact at AMR to call regarding ambulance billing questions. Also, if a HICAP/SMP advocate calls and states they are working with a beneficiary to appeal/resolve their ambulance trip directly with Medicare, AMR’s billing service, Patient Business Services (PBS) will automatically put the beneficiary’s account on hold for 90 days; this is two 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 and awaiting Medicare’s redetermination on the claim.
This is a great step forward in advocate and provider collaboration and a great win for beneficiaries. An article on a beneficiary whose successful ambulance appeal relates directly to this new agreement will be posted soon.
See Medicare’s Coverage of Ambulance Services (PDF), for more information on Medicare’s coverage of ambulance services.