Does Insurance Have to Pay an Out-of-Network Ambulance Bill in Full?

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Kennedy
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Does Insurance Have to Pay an Out-of-Network Ambulance Bill in Full?

Postby Kennedy » Wed Apr 19, 2017 2:52 pm

A family member was driven to Hospital A in a private car and was then was admitted. They were transferred to Hospital B the next day. The doctor recommended the transfer since Hospital B had a higher-level care that the family member required.

The transfer was via an ambulance operated by a small town. The ambulance company was not in-network with our insurance company.

When the EOB arrived, our insurance had paid about 50% of the bill, and there was a note stating that if the City (ambulance) billed us for the difference, we were to contact a third party group that provided fair estimates on ambulance bills. Well... the City billed us for the balance. We called the third party who tried to get the City to accept the lower rate already paid by the insurance. The City refused and is billing us, still, for the balance.

Any thoughts? I would assume that if the ambulance did not tell us they were out of network and what the fee would be, they could only charge a "reasonable" fee. I would further assume that the reasonable fee would be determined by the independent third party. After all, what's to stop the ambulance company from billing us any amount at all of their choosing without disclosure?

Broken Man 1999
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Re: Does Insurance Have to Pay an Out-of-Network Ambulance Bill in Full?

Postby Broken Man 1999 » Wed Apr 19, 2017 4:20 pm

My last ride, and my MIL's last two rides, in my city's ambulances resulted in bills, some remainder after insurance paid. I don't remember the exact details, but I think both insurances paid a bit over half the charge.

So, at least my experiences the insurance company did not pay the bill in full, in network or out.

With ambulances, I'm not even sure that they appear in networks.

There are private ambulances, I believe, but at least for MIL's rides the original calls were via E911. My ride was set up by calling fire department non-emergency line and requesting a ride to hospital, as I had smashed my knee and I couldn't get into my wheelchair to seek medical aid.

Broken Man 1999

downshiftme
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Re: Does Insurance Have to Pay an Out-of-Network Ambulance Bill in Full?

Postby downshiftme » Wed Apr 19, 2017 4:26 pm

In network hospital arranged transpiration for me (a patient) with their usual ambulance service to another in network facility for covered treatment. The ambulance ride was not covered by insurance. Balance billing is disallowed for in-network providers who have agreed to the insurance network's terms. Out of network providers can balance bill. Uncovered services, like ambulance rides under many plans, can bill whatever they want.

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patriciamgr2
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Re: Does Insurance Have to Pay an Out-of-Network Ambulance Bill in Full?

Postby patriciamgr2 » Wed Apr 19, 2017 4:46 pm

I'm not aware of any requirement that medical service providers disclose to you that they're not in-network under your policy. In general, a patient is always responsible for determining his own coverage. The fact that a provider "accepts" your insurance does not mean they agree to limit their billing to in-network charges.

Did the patient sign any of the typical paperwork guaranteeing payment in excess of the amount paid by insurance? The time to raise this issue would have been before signing that document and taking the ambulance ride. Calling your insurer at that point to find in-network transport or (if none available) to get pre-approved for the service you used would have been better.

At this point, I'd suggest contacting the billing office of the hospital (assuming it was the hospital which suggested that ambulance service). What lower-priced ambulance services exist in that area? If there are no competitors that are in-network, try a formal appeal of the insurance company's decision. If no ambulances provide service for the "reasonable" fee, you can argue it's not reasonable for your area.

The key lesson for all of us is that we need to check coverage at each step of treatment: not all physicians, laboratories, etc. will be in-network even if the hospital is. It's insane, but (in my state) it's been like this for the last 7-10 years. For office visits, after I verify that a doc is in-network, I caveat the financial responsibility paperwork with a statement that I am relying on doc being in-network with BCBS PPO (inserting the number of my specific plan), the name of doc's billing person who confirmed in-network status, & that I'm only responsible for in-network fees. When there is a balance (attributable to deductible, etc), I pay very promptly. I don't expect physicians to finance my bills; I just want to be clear on what I owe.

sawhorse
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Re: Does Insurance Have to Pay an Out-of-Network Ambulance Bill in Full?

Postby sawhorse » Wed Apr 19, 2017 5:03 pm

patriciamgr2 wrote:I'm not aware of any requirement that medical service providers disclose to you that they're not in-network under your policy. In general, a patient is always responsible for determining his own coverage. The fact that a provider "accepts" your insurance does not mean they agree to limit their billing to in-network charges.

Did the patient sign any of the typical paperwork guaranteeing payment in excess of the amount paid by insurance? The time to raise this issue would have been before signing that document and taking the ambulance ride. Calling your insurer at that point to find in-network transport or (if none available) to get pre-approved for the service you used would have been better.

At this point, I'd suggest contacting the billing office of the hospital (assuming it was the hospital which suggested that ambulance service). What lower-priced ambulance services exist in that area? If there are no competitors that are in-network, try a formal appeal of the insurance company's decision. If no ambulances provide service for the "reasonable" fee, you can argue it's not reasonable for your area.

The key lesson for all of us is that we need to check coverage at each step of treatment: not all physicians, laboratories, etc. will be in-network even if the hospital is. It's insane, but (in my state) it's been like this for the last 7-10 years. For office visits, after I verify that a doc is in-network, I caveat the financial responsibility paperwork with a statement that I am relying on doc being in-network with BCBS PPO (inserting the number of my specific plan), the name of doc's billing person who confirmed in-network status, & that I'm only responsible for in-network fees. When there is a balance (attributable to deductible, etc), I pay very promptly. I don't expect physicians to finance my bills; I just want to be clear on what I owe.
I don't know the specifics of this case of course, but what you are saying is completely unreasonable for someone in an emergency medical situation.

The last time I had to take an ambulance I was curled up on the ground in so much pain that someone else had to call. I was in no condition to think about finances or insurance networks.

Even in non emergency situations, it's very difficult for someone with a debilitating medical condition to keep on top of everything because you're in poor health.

sawhorse
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Re: Does Insurance Have to Pay an Out-of-Network Ambulance Bill in Full?

Postby sawhorse » Wed Apr 19, 2017 5:07 pm

downshiftme wrote:In network hospital arranged transpiration for me (a patient) with their usual ambulance service to another in network facility for covered treatment. The ambulance ride was not covered by insurance. Balance billing is disallowed for in-network providers who have agreed to the insurance network's terms. Out of network providers can balance bill. Uncovered services, like ambulance rides under many plans, can bill whatever they want.

Some states have restrictions on billing in situations like this. What state are you in?

I was in a similar situation. They wouldn't let me take a taxi to the other facility. I asked many times because it was close by and I could physically get there by taxi, but they insisted on putting me in an ambulance even though I could walk fine. I often wonder if they do that on purpose for the money.

lightheir
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Re: Does Insurance Have to Pay an Out-of-Network Ambulance Bill in Full?

Postby lightheir » Wed Apr 19, 2017 5:12 pm

Unfortunately, reason doesn't seem to matter for the current insane billing practices that are totally legal.

My last visit to my local ER, I went to my local in-network ER that is only a few miles from my house. (Fortunately, I could drive myself there.)

Was seen by an ER doc there. At the 'in-network' ER.

The insurance covered the in-network ER bill, but the doctor's bill was billed from out-of-state in Colorado. And no, there doctor does NOT fly in from Colorado to work here in Norcal - the MD lives very near me. They intentionally bill from out-of-state to get the higher out of network fee.

So I wasn't nearly as surprised when later my spouse was in the same in-network hospital as that ER, was seen by a non-ER MD while she was inpatient, and the same thing happened. Insurance covered all of the (big) inpatient hospital facility bill, but the ordering MD yet again billed from - you guessed it - Colorado, the same facility I got the ER MD bill from.

If they can pull this kind of BS (similar behavior was written about in a NYT articles a few months back), I wouldn't be surprised with ambulance billing shenanigans that should be illegal but aren't.

runner3081
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Re: Does Insurance Have to Pay an Out-of-Network Ambulance Bill in Full?

Postby runner3081 » Wed Apr 19, 2017 5:19 pm

Broken Man 1999 wrote:With ambulances, I'm not even sure that they appear in networks.

I had thought the same thing, but the show up in the BCBS of AZ listings as in-network.

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Pajamas
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Re: Does Insurance Have to Pay an Out-of-Network Ambulance Bill in Full?

Postby Pajamas » Wed Apr 19, 2017 5:21 pm

These situations happen because health care is one of the few things that people buy without knowing what it costs in advance. It is also very expensive. The person who arranged the transportation could have easily picked up the phone and called the insurance company or even looked on their website to find an in-network provider of transportation services, but they didn't bother to do so.

If the ambulance service refuses to negotiate or give a discount, you can either pay the balance or not pay it. You can ask them what will happen if you are unable to pay it, specifically whether it will go to an outside collection agency and/or reported to credit bureaus.

You can also appeal to your insurance company. They should pay it in full if it was considered an emergency transfer, which it does not sound like it was, or if there were no in-network transportation providers available. You might also appeal it on the basis that the first facility could not provide the needed services, but that probably does not override the fact that the transportation provider was out-of-network if an in-network provider was available. Read the section in your contract about ambulances very carefully to see what it says.

Consider yourself fortunate that the insurance paid for any of it. Some types of coverage don't pay anything for non-emergent out-of-network services.

sawhorse wrote:I was in a similar situation. They wouldn't let me take a taxi to the other facility. I asked many times because it was close by and I could physically get there by taxi, but they insisted on putting me in an ambulance even though I could walk fine. I often wonder if they do that on purpose for the money.


Ground transfers between facilities are always done by ambulance. Any other form of ground transportation would not include medical supervision and the availability of medical assistance if needed and would break the chain of continuous care. If you are being discharged, you no longer need continuous monitoring and can travel by any method, although in some cases the facility may require that you be accompanied by someone rather than leave alone.

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Kenkat
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Re: Does Insurance Have to Pay an Out-of-Network Ambulance Bill in Full?

Postby Kenkat » Wed Apr 19, 2017 5:30 pm

I know in a couple of situations where 911 was called, my local township EMS accepted whatever the insurance company would pay. In fact, they made a point to ask if there was private insurance and that they would accept whatever they paid as payment in full - because any payment is helpful to them in providing service. In other words, they were obligated to respond to the 911 emergency and taxpayers cover any unreimbursed costs.

This is maybe a little different in that it wasn't a 911 situation. I would tell the town you don't have any money and can't pay and see what they say.

Spirit Rider
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Re: Does Insurance Have to Pay an Out-of-Network Ambulance Bill in Full?

Postby Spirit Rider » Wed Apr 19, 2017 6:49 pm

That is the difference. Emergency services usually accept in-network payment amounts. In some cases I think it might be mandated. However, not all ambulance rides are considered emergencies. Intra-facility transfers are not usually considered emergencies. Unfortunately, many of these are done by ambulance and you are stuck with the excess charges. Welcome to our Byzantine medical care billing system.

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patriciamgr2
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Re: Does Insurance Have to Pay an Out-of-Network Ambulance Bill in Full?

Postby patriciamgr2 » Wed Apr 19, 2017 11:28 pm

Sawhorse: The OP said this was a transfer the doctor thought was beneficial the day after the patient's admission. It's unlikely it would be considered an emergency. If it's a true emergency (like the writhing in pain situation you described) most policies allow for out-of-network providers. That wasn't the fact pattern presented by the OP, however.

Actions by insurance companies and medical providers indeed may be "unreasonable"; have you actually succeeded in avoiding balance billing in non-emergency situations? If so, please let us know--did the insurer pay more than the contract price or did the provider discount its bill? Just saying it's "unreasonable" doesn't seem helpful to me. Are you saying the bill isn't legally enforceable? The OP's relative is faced with an actual bill, and aggressive collection efforts on medical bills are becoming commonplace.

I have helped people with their bills and I've seen balance billing on (1) ER docs' bills even when the hospital was in-network, (2) radiologists' bills for reading mammograms even when the facility advertised it was in-network; & (3) anesthesiologist's bills when a surgeon & facility were both in-network. In some cases, the appeals were successful. I hope these abuses are corrected, but until then, I suggest families of patients protect themselves as best they can without compromising quality of care.

NOLA
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Re: Does Insurance Have to Pay an Out-of-Network Ambulance Bill in Full?

Postby NOLA » Wed Apr 19, 2017 11:51 pm

lightheir wrote:Unfortunately, reason doesn't seem to matter for the current insane billing practices that are totally legal.

My last visit to my local ER, I went to my local in-network ER that is only a few miles from my house. (Fortunately, I could drive myself there.)

Was seen by an ER doc there. At the 'in-network' ER.

The insurance covered the in-network ER bill, but the doctor's bill was billed from out-of-state in Colorado. And no, there doctor does NOT fly in from Colorado to work here in Norcal - the MD lives very near me. They intentionally bill from out-of-state to get the higher out of network fee.

So I wasn't nearly as surprised when later my spouse was in the same in-network hospital as that ER, was seen by a non-ER MD while she was inpatient, and the same thing happened. Insurance covered all of the (big) inpatient hospital facility bill, but the ordering MD yet again billed from - you guessed it - Colorado, the same facility I got the ER MD bill from.

If they can pull this kind of BS (similar behavior was written about in a NYT articles a few months back), I wouldn't be surprised with ambulance billing shenanigans that should be illegal but aren't.



This is just sad. How can they be allowed to act like that.

littlebird
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Re: Does Insurance Have to Pay an Out-of-Network Ambulance Bill in Full?

Postby littlebird » Thu Apr 20, 2017 12:43 am

Spirit Rider wrote:That is the difference. Emergency services usually accept in-network payment amounts. In some cases I think it might be mandated. However, not all ambulance rides are considered emergencies. Intra-facility transfers are not usually considered emergencies. Unfortunately, many of these are done by ambulance and you are stuck with the excess charges. Welcome to our Byzantine medical care billing system.


Yes, happened to us too. The transfer actually was a medical emergency (brain bleed), but it was called in as a NON-emergency and the resultant bill was very high. I (eventually) got the hospital ombudsperson to research the incident and she called the ambulance company to have them change the coding to "emergency". The bill went down substantially. Lesson: Medical Transport is a lower level of service and may be a better means of inter-facility non-emergency transportation. Social Services can supply several names and family/patient can arrange. I have 2 on my phone's caller list from spouse's days as frequent ER visitor. Good way to get a less mobile patient home from the ER in the middle of the night also.

There's a reason why they say getting old's "not for sissies".

toofache32
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Re: Does Insurance Have to Pay an Out-of-Network Ambulance Bill in Full?

Postby toofache32 » Thu Apr 20, 2017 2:08 am

sawhorse wrote:
downshiftme wrote:In network hospital arranged transpiration for me (a patient) with their usual ambulance service to another in network facility for covered treatment. The ambulance ride was not covered by insurance. Balance billing is disallowed for in-network providers who have agreed to the insurance network's terms. Out of network providers can balance bill. Uncovered services, like ambulance rides under many plans, can bill whatever they want.

Some states have restrictions on billing in situations like this. What state are you in?

I was in a similar situation. They wouldn't let me take a taxi to the other facility. I asked many times because it was close by and I could physically get there by taxi, but they insisted on putting me in an ambulance even though I could walk fine. I often wonder if they do that on purpose for the money.


It's because of liability. Don't you see the billboards put up by attorneys looking for a lottery ticket?

toofache32
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Re: Does Insurance Have to Pay an Out-of-Network Ambulance Bill in Full?

Postby toofache32 » Thu Apr 20, 2017 2:09 am

None of this would be an issue if insurance companies paid reasonable rates to begin with. Everyone would want to be in-network.

sawhorse
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Re: Does Insurance Have to Pay an Out-of-Network Ambulance Bill in Full?

Postby sawhorse » Thu Apr 20, 2017 7:15 am

patriciamgr2 wrote:Actions by insurance companies and medical providers indeed may be "unreasonable"; have you actually succeeded in avoiding balance billing in non-emergency situations? If so, please let us know--did the insurer pay more than the contract price or did the provider discount its bill? Just saying it's "unreasonable" doesn't seem helpful to me. Are you saying the bill isn't legally enforceable? The OP's relative is faced with an actual bill, and aggressive collection efforts on medical bills are becoming commonplace.

I was referring to your comments that the patient always has the responsibility of being on top of things in terms of verifying coverage. That is the unreasonable part, to expect patients to always be able to do that. In an emergency situation that's impossible. In a non-emergency situation when there is a serious medical problem (as opposed to a preventative checkup for a healthy person), it's very difficult because you're struggling so much with your health problems already.

In addition, the people that should know whether things are covered often give wrong information. I've had insurance companies tell me something isn't covered. Lo and behold, it was. I've also had the opposite situation.

Here is what you wrote. It's absolutely unreasonable to expect an ill patient to go through all these steps. In particular, the ambulance situation can take place when the insurance company is closed. The customer service line closes at 4:30 at my insurance, and one time during regular hours I had to wait 50 minutes.

patriciamgr2 wrote:I'm not aware of any requirement that medical service providers disclose to you that they're not in-network under your policy. In general, a patient is always responsible for determining his own coverage. The fact that a provider "accepts" your insurance does not mean they agree to limit their billing to in-network charges.

Did the patient sign any of the typical paperwork guaranteeing payment in excess of the amount paid by insurance? The time to raise this issue would have been before signing that document and taking the ambulance ride. Calling your insurer at that point to find in-network transport or (if none available) to get pre-approved for the service you used would have been better.

At this point, I'd suggest contacting the billing office of the hospital (assuming it was the hospital which suggested that ambulance service). What lower-priced ambulance services exist in that area? If there are no competitors that are in-network, try a formal appeal of the insurance company's decision. If no ambulances provide service for the "reasonable" fee, you can argue it's not reasonable for your area.

The key lesson for all of us is that we need to check coverage at each step of treatment: not all physicians, laboratories, etc. will be in-network even if the hospital is. It's insane, but (in my state) it's been like this for the last 7-10 years. For office visits, after I verify that a doc is in-network, I caveat the financial responsibility paperwork with a statement that I am relying on doc being in-network with BCBS PPO (inserting the number of my specific plan), the name of doc's billing person who confirmed in-network status, & that I'm only responsible for in-network fees. When there is a balance (attributable to deductible, etc), I pay very promptly. I don't expect physicians to finance my bills; I just want to be clear on what I owe.

pshonore
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Re: Does Insurance Have to Pay an Out-of-Network Ambulance Bill in Full?

Postby pshonore » Thu Apr 20, 2017 8:15 am

toofache32 wrote:None of this would be an issue if insurance companies paid reasonable rates to begin with. Everyone would want to be in-network.
I'm sure insurance companies would love to pay "reasonable rates". However they're really just passing through premium dollars. A significant increase in payouts would just raise premiums significantly. But we could always go to a single payer system if that's preferable.

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patriciamgr2
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Re: Does Insurance Have to Pay an Out-of-Network Ambulance Bill in Full?

Postby patriciamgr2 » Thu Apr 20, 2017 8:41 am

Sawhorse: I believe I am reflecting the current state of insurance coverage. I'm not defending this insanity.

I repeat my question: is your statement just your opinion of how insurance/medical billing should work in a better world, or are you advising OP he can contest the actual bill successfully now ? If it's the former, I agree. If it's the latter, I'd be interested in your experiences and whether it was the provider or the insurer who "blinked" & what the winning argument was. That would be extremely helpful to the OP's relative.

Family members or friends need to stay on top of insurance issues. If a patient is alone, I'd suggest--if at all possible--addressing billing issues before signing consent forms by insisting that the billing department of the hospital focus on in-network issues. If the procedure, etc. doesn't require consent, logically it should be covered out-of-network as an "emergency".

I don't work for any insurer or medical provider. I have done volunteer work helping people who just assumed everything would be covered by insurance and got stuck with a huge balance bill. To the extent I can help anyone avoid that fate, I'd like to do so.

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DaftInvestor
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Re: Does Insurance Have to Pay an Out-of-Network Ambulance Bill in Full?

Postby DaftInvestor » Thu Apr 20, 2017 8:50 am

I've been in similar circumstances and haven't found anything additional to do other than pay the bill and try to avoid the situation next time. If the insurance company actually paid 50% of the FULL bill (as they are obligated to) you are a step ahead of were I usually start.
(In my case I went in for a medical procedure with an in-network doctor at an in-network hospital. Somehow, as I found out later, the anesthesiologist wasn't in-network and their bill was actually higher than the Doctor/Surgeons. Insurance paid 50% of "reasonable" charge versus 50% of the full charge - I was stuck with nearly 70% of the bill (since the 50% of reasonable charge was only 30% of the actual charge) - I did get the insurance company to eventually pay 50% of the full charge but, of course, I was still stuck with 50% of the full charge. All the time lost trying to get the insurance company to pay the full 50% after negotiations over trying to get the anesthesiologist to accept the "reasonable" charge was what really ticked me off - versus the actual final bill. I'm not sure how you can be 100% sure that everyone involved in a procedure will be in network at the beginning and throughout. This has all gotten far worse under Obamacare).

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patriciamgr2
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Re: Does Insurance Have to Pay an Out-of-Network Ambulance Bill in Full?

Postby patriciamgr2 » Thu Apr 20, 2017 8:53 am

Another practical suggestion:

Often, the provider's billing department can get through to the insurer on a provider line faster than the patient can reach a representative by telephone. Also, with a provider the hospital uses routinely (like the ambulance service they recommended to OP's relative), the hospital billing department should be able to verify network status with their contact at the provider.

I agree with Toofache's comment that ridiculous in-network prices being imposed on providers is one of the root causes of all of this confusion and the ever-declining networks. I personally chose to stay with a PPO just because of the limited networks available under more affordable plans.

Best Wishes to us all as we try to navigate this increasingly horrific landscape.

whomever
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Re: Does Insurance Have to Pay an Out-of-Network Ambulance Bill in Full?

Postby whomever » Thu Apr 20, 2017 9:03 am

There are several posts that say 'I wanted to arrange my own transportation from Facility A to Facility B, but they wouldn't let me'.

As a matter of law, I don't see how a hospital can stop you if you announce you're leaving.

This assumes you're ambulatory, of course.

sawhorse
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Re: Does Insurance Have to Pay an Out-of-Network Ambulance Bill in Full?

Postby sawhorse » Thu Apr 20, 2017 9:16 am

Last time I was in the hospital, admitted through the emergency room, thankfully I was in an in-network hospital with an in-network hospitalist doctor.

I was in so much pain that it didn't occur to me to ask about those things.

For a situation in which you go to the emergency room in an out of network hospital and are admitted, what options do patients have? It sounds like transferring to an in network hospital could incur a high ambulance cost particularly if the in network hospital is far away.

In addition, what if the hospitalist is not in network? It's not as if you can demand to be seen by an in network one because they work in shifts, and who knows when you'll be able to get one in network.

Are hospitalists required to tell you that they're not in network and provide a written quote and explain your options? The same for specialists called upon to consult during your time there.

And what if you don't have the ability to call the insurance company during your stay due to physical limitations (e.g. can't talk), because they confiscate your phone (e.g. psychiatric stays), or you don't have a phone nor your insurance information (e.g. car accident in which your possessions were lost in the wreckage)?

It seems like hospitalized patients are pretty powerless.
Last edited by sawhorse on Thu Apr 20, 2017 9:24 am, edited 1 time in total.

Rupert
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Re: Does Insurance Have to Pay an Out-of-Network Ambulance Bill in Full?

Postby Rupert » Thu Apr 20, 2017 9:21 am

whomever wrote:There are several posts that say 'I wanted to arrange my own transportation from Facility A to Facility B, but they wouldn't let me'.

As a matter of law, I don't see how a hospital can stop you if you announce you're leaving.

This assumes you're ambulatory, of course.


I don't think they could stop you, but you would have to sign all sorts of paperwork acknowledging that you are now on your own, i.e., leaving against medical advice. This also means that whatever arrangements they had made with the second hospital would fall through, and you'd probably have to enter that facility via their ER. That would probably result in you be re-tested for whatever it is the first hospital thinks you have, etc., and possibly being seen at some point by some out-of-network doctor or something. So, really, there's no practical solution here. In the end, it will probably be cheaper to just pay the out-of-network ambulance fee.

rantk81
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Re: Does Insurance Have to Pay an Out-of-Network Ambulance Bill in Full?

Postby rantk81 » Thu Apr 20, 2017 9:24 am

The whole situation in the United States about in-network vs out-of-network health insurance claims is completely unfair.

As previous posters have pointed out, it is not always possible to find out whether providers are in network or not, prior to receiving care. Sometimes you are unconscious, and never actually see who is giving you care. Sometimes neither the insurance company nor the provider can accurately tell you whether or not it is in network!

When I had some health issues about a decade ago, I went to one provider and "confirmed" with both the provider and with my insurance company's website that they were indeed in-network. However, apparently they were both operating off of "incorrect/outdated" information, and all the billing ended up being out-of-network. After months of trying to fight it, I gave up in order to protect my credit score, under the threat of it being sent to collections.
Last edited by rantk81 on Thu Apr 20, 2017 9:44 am, edited 1 time in total.

Nate79
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Re: Does Insurance Have to Pay an Out-of-Network Ambulance Bill in Full?

Postby Nate79 » Thu Apr 20, 2017 9:41 am

As someone posted the situation with insurance, in network/out of network, and balance billing is completely different for emergency vs non emergency situation. Since this was non emergency you get the raw end of the deal.

sawhorse
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Re: Does Insurance Have to Pay an Out-of-Network Ambulance Bill in Full?

Postby sawhorse » Thu Apr 20, 2017 9:45 am

whomever wrote:There are several posts that say 'I wanted to arrange my own transportation from Facility A to Facility B, but they wouldn't let me'.

As a matter of law, I don't see how a hospital can stop you if you announce you're leaving.

This assumes you're ambulatory, of course.
On the advice of a friend I had confided in, I went to the hospital when I was feeling very depressed and having panic attacks. I don't know if I would have been allowed to leave.

It nearly bankrupted me as insurance didn't cover it since it was a pre existing condition. (This was a decade ago.)

They also took my phone, so even today with insurance I wouldn't have been able to contact the insurance company.

In hindsight, I strongly regret going to the hospital because the financial ramifications were too great. I lost my job due to not being able to contact them from the hospital, and I was only making $23k anyway. Bankruptcy was a very real possibility for a while.

I wonder what would happen today if the hospital and/or doctor were out of network. At the minimum you'd have a large deductible and might have to pay for the ambulance to be transferred to an in network hospital.

Is it possible the insurance company wouldn't pay anything and you'd be required to stay at the out of network hospital?

@patriciamgr2 What would you recommend for a patient in that situation taking into account the mental limitations a patient might have in such a situation and the possibility they wouldn't be able to contact the insurance company nor have a friend or family member who could take care of some of the tasks?

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Re: Does Insurance Have to Pay an Out-of-Network Ambulance Bill in Full?

Postby sk.dolcevita » Thu Apr 20, 2017 9:54 am

In one word - Kaiser.

My healthcare aspect of our life has been transformed and has become worry-free ever since we moved to Kaiser. I wish they had presence in more locations.

sawhorse
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Re: Does Insurance Have to Pay an Out-of-Network Ambulance Bill in Full?

Postby sawhorse » Thu Apr 20, 2017 9:57 am

sk.dolcevita wrote:In one word - Kaiser.

My healthcare aspect of our life has been transformed and has become worry-free ever since we moved to Kaiser. I wish they had presence in more locations.

The reality is that most Americans don't have access to Kaiser.

Does Kaiser only use in network everything (doctors, labs, ambulances, etc) at their in network hospitals? What about situations that happen while you're traveling?

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Re: Does Insurance Have to Pay an Out-of-Network Ambulance Bill in Full?

Postby Pajamas » Thu Apr 20, 2017 9:58 am

rantk81 wrote:
As previous posters have pointed out, it is not always possible to find out whether providers are in network or not, prior to receiving care. Sometimes you are unconscious, and never actually see who is giving you care.


Emergency care is always or almost always covered equally in or out of network.
Last edited by Pajamas on Thu Apr 20, 2017 10:03 am, edited 1 time in total.

EagertoLearnMore
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Re: Does Insurance Have to Pay an Out-of-Network Ambulance Bill in Full?

Postby EagertoLearnMore » Thu Apr 20, 2017 10:01 am

EMS Subscription

Some towns offer yearly subscription services that you PAY to belong to the local EMS service. You can select individual, couple, family. BUT -- no visitors, only residents of the home.

Then if you or member needs to use the ambulance they will accept whatever your insurance is willing to pay. Yes, they balance bill, but you call and say look at subscription and difference from insurance payment is forgiven.

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Re: Does Insurance Have to Pay an Out-of-Network Ambulance Bill in Full?

Postby sawhorse » Thu Apr 20, 2017 10:02 am

Pajamas wrote:
rantk81 wrote:
As previous posters have pointed out, it is not always possible to find out whether providers are in network or not, prior to receiving care. Sometimes you are unconscious, and never actually see who is giving you care.


Emergency care is always or almost always covered in full in or out of network.
In some states, the emergency room doctor can still bill you for the difference between their fee and the insurance payment. I imagine a radiologist and others involved in your care can do the same.

sawhorse
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Re: Does Insurance Have to Pay an Out-of-Network Ambulance Bill in Full?

Postby sawhorse » Thu Apr 20, 2017 10:04 am

EagertoLearnMore wrote:EMS Subscription

Some towns offer yearly subscription services that you PAY to belong to the local EMS service. You can select individual, couple, family. BUT -- no visitors, only residents of the home.

Then if you or member needs to use the ambulance they will accept whatever your insurance is willing to pay. Yes, they balance bill, but you call and say look at subscription and difference from insurance payment is forgiven.

Isn't this a recipe for emergency room usage abuse?

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Re: Does Insurance Have to Pay an Out-of-Network Ambulance Bill in Full?

Postby an_asker » Thu Apr 20, 2017 10:04 am

Kennedy wrote:A family member was driven to Hospital A in a private car and was then was admitted. They were transferred to Hospital B the next day. The doctor recommended the transfer since Hospital B had a higher-level care that the family member required.

The transfer was via an ambulance operated by a small town. The ambulance company was not in-network with our insurance company.

When the EOB arrived, our insurance had paid about 50% of the bill, and there was a note stating that if the City (ambulance) billed us for the difference, we were to contact a third party group that provided fair estimates on ambulance bills. Well... the City billed us for the balance. We called the third party who tried to get the City to accept the lower rate already paid by the insurance. The City refused and is billing us, still, for the balance.

Any thoughts? I would assume that if the ambulance did not tell us they were out of network and what the fee would be, they could only charge a "reasonable" fee. I would further assume that the reasonable fee would be determined by the independent third party. After all, what's to stop the ambulance company from billing us any amount at all of their choosing without disclosure?

Your family member is definitely luckier than me! In my case (it's been a few years, so I don't remember exact details), insurance didn't pay a penny. I had to pay what was billed.

OnTrack2020
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Re: Does Insurance Have to Pay an Out-of-Network Ambulance Bill in Full?

Postby OnTrack2020 » Thu Apr 20, 2017 10:49 am

My thought is that you will need to send an appeal letter to your insurance company to pay in-network, as you mentioned this is a small-town ambulance and you were not given the option of having any other in-network ambulance service provide transportation. Is this correct? If that is the case, then it really needs to be treated as in-network.

We have a similar, but different, situation, and we've basically always had to appeal. It certainly can't hurt to appeal.

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Re: Does Insurance Have to Pay an Out-of-Network Ambulance Bill in Full?

Postby patriciamgr2 » Thu Apr 20, 2017 10:50 am

Sawhorse: If the situation you described (voluntary admission to a psychiatric facility in a situation an insurer would probably not regard as an emergency) were to occur, I'd suggest discussing insurance coverage BEFORE you enter the facility--first with your insurer & then with the facility. On the paperwork the patient is asked to sign, indicate that you are relying on the facility & its providers being in-network because X (name of persons with whom you spoke) informed you of that. It's not absolute protection, but it's better than saying nothing.

If they refuse to admit you, you can try using whichever facility your insurer states is in-network if they have beds. Many policies have very limited psychiatric benefits.

Remember, I'm not suggesting I would design a system to run like our healthcare system does, but I'm not going to just express indignation and lull unsuspecting future patients into thinking that if a bill seems unfair no one will try to collect it from them.

From the providers' point of view, some insurers are paying in-network fees that are extremely low. I understand providers' frustration that just because a patient who walks in with coverage from one of these disgusting plans thinks they are covered, the provider must automatically discount its rates to whatever that insurer (with whom they have no contract) dictates.

I understand that insurers are trying to cut costs.

Mostly, however, I sympathize with patients who are caught in a horrifying Catch22 situation at a time when they are at their most vulnerable. [BTW, the backing-away from an assurance that a provider is in-network is particularly galling to me. I understand that sometimes it happens because the contracts are so complicated, doctors in particular may not know if the patient's specific plan is covered by the contract he signed. For example, I have a private (non-marketplace) BCBS PPO policy that provides better payments (I am told) than the marketplace BCBS. Nevertheless, whenever I sign a financial responsibility document (& yes, I'm healthy, so it's easier for me), I caveat it by saying I'm relying on in-network status & agree to pay charges at those levels & give the specific numbers/information about my plan.]

Key takeaway: Until this situation is improved (in my state, it pre-dated Obamacare by many years), patients need to be proactive about insurance coverage of medical bills. You'll probably need to check/contest bills in any event, but the more you do up-front to protect yourself, the better it will be for you. It's important to understand how your policy works: who is in-network?; will transportation to an in-network facility after emergency admission to an out-of-network hospital be covered?; are other medical transport options (less expensive than ambulances, but not as well equipped or staffed) available in your area?, etc.

Again, good luck to all of us as we deal with these difficult issues.

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Re: Does Insurance Have to Pay an Out-of-Network Ambulance Bill in Full?

Postby Rupert » Thu Apr 20, 2017 11:14 am

patriciamgr2 wrote:Sawhorse: If the situation you described (voluntary admission to a psychiatric facility in a situation an insurer would probably not regard as an emergency) were to occur, I'd suggest discussing insurance coverage BEFORE you enter the facility--first with your insurer & then with the facility. On the paperwork the patient is asked to sign, indicate that you are relying on the facility & its providers being in-network because X (name of persons with whom you spoke) informed you of that. It's not absolute protection, but it's better than saying nothing.

If they refuse to admit you, you can try using whichever facility your insurer states is in-network if they have beds. Many policies have very limited psychiatric benefits.

Remember, I'm not suggesting I would design a system to run like our healthcare system does, but I'm not going to just express indignation and lull unsuspecting future patients into thinking that if a bill seems unfair no one will try to collect it from them.

From the providers' point of view, some insurers are paying in-network fees that are extremely low. I understand providers' frustration that just because a patient who walks in with coverage from one of these disgusting plans thinks they are covered, the provider must automatically discount its rates to whatever that insurer (with whom they have no contract) dictates.

I understand that insurers are trying to cut costs.

Mostly, however, I sympathize with patients who are caught in a horrifying Catch22 situation at a time when they are at their most vulnerable. [BTW, the backing-away from an assurance that a provider is in-network is particularly galling to me. I understand that sometimes it happens because the contracts are so complicated, doctors in particular may not know if the patient's specific plan is covered by the contract he signed. For example, I have a private (non-marketplace) BCBS PPO policy that provides better payments (I am told) than the marketplace BCBS. Nevertheless, whenever I sign a financial responsibility document (& yes, I'm healthy, so it's easier for me), I caveat it by saying I'm relying on in-network status & agree to pay charges at those levels & give the specific numbers/information about my plan.]

Key takeaway: Until this situation is improved (in my state, it pre-dated Obamacare by many years), patients need to be proactive about insurance coverage of medical bills. You'll probably need to check/contest bills in any event, but the more you do up-front to protect yourself, the better it will be for you. It's important to understand how your policy works: who is in-network?; will transportation to an in-network facility after emergency admission to an out-of-network hospital be covered?; are other medical transport options (less expensive than ambulances, but not as well equipped or staffed) available in your area?, etc.

Again, good luck to all of us as we deal with these difficult issues.


You nailed it. I carry my health insurance "Summary of Benefits and Coverage" around with me everywhere I go. I keep a copy of the full insurance contract on top of my desk at home, where it's readily retrievable. More people need to do this. A stunningly large number of posters on healthcare topics here at Bogleheads, where most people are pretty sophisticated consumers in general, don't seem to know the details of their own insurance coverage.

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Re: Does Insurance Have to Pay an Out-of-Network Ambulance Bill in Full?

Postby sawhorse » Thu Apr 20, 2017 12:24 pm

patriciamgr2 wrote:On the paperwork the patient is asked to sign, indicate that you are relying on the facility & its providers being in-network because X (name of persons with whom you spoke) informed you of that. It's not absolute protection, but it's better than saying nothing.

Would writing that disclaimer on the paperwork actually affect your financial responsibility?

What would you recommend if you're physically or mentally unable (arm in a sling, cognitively affected by painkillers or other medication, etc)?

I'd be concerned about being flagged as a problem patient for writing something like this. This is particularly an issue for psych patients, but it can be a concern for any patients.

Also what do you recommend when you can't get through to someone at the insurance company? For example, the office is closed or you don't have your phone. You mentioned having the hospital billing office make the call for you, but what if they are closed?

By the way the last time I was hospitalized I don't remember whether they made me sign something additional for the hospital admission, or whether it was only when I got into the emergency room when I was in severe pain. I don't even recall signing anything in the emergency room. I probably did and forgot because I was in so much pain.

When you're in the in network hospital, what happens if the hospitalist or other doctor consulted (radiologist, etc) is out of network? As both the doctors and nurses work in shifts, the nurses might not be able to tell you who is going to be the hospitalist checking on you, and I'm not sure what you can do anyway.

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Re: Does Insurance Have to Pay an Out-of-Network Ambulance Bill in Full?

Postby Rupert » Thu Apr 20, 2017 1:36 pm

sawhorse wrote:
patriciamgr2 wrote:On the paperwork the patient is asked to sign, indicate that you are relying on the facility & its providers being in-network because X (name of persons with whom you spoke) informed you of that. It's not absolute protection, but it's better than saying nothing.

Would writing that disclaimer on the paperwork actually affect your financial responsibility?

What would you recommend if you're physically or mentally unable (arm in a sling, cognitively affected by painkillers or other medication, etc)?

I'd be concerned about being flagged as a problem patient for writing something like this. This is particularly an issue for psych patients, but it can be a concern for any patients.

Also what do you recommend when you can't get through to someone at the insurance company? For example, the office is closed or you don't have your phone. You mentioned having the hospital billing office make the call for you, but what if they are closed?

By the way the last time I was hospitalized I don't remember whether they made me sign something additional for the hospital admission, or whether it was only when I got into the emergency room when I was in severe pain. I don't even recall signing anything in the emergency room. I probably did and forgot because I was in so much pain.

When you're in the in network hospital, what happens if the hospitalist or other doctor consulted (radiologist, etc) is out of network? As both the doctors and nurses work in shifts, the nurses might not be able to tell you who is going to be the hospitalist checking on you, and I'm not sure what you can do anyway.


There are going to be some situations where there is absolutely nothing you can do to avoid surprise bills or lower costs. Unless/until we implement a single payer system in this country (or some alternate system that includes price controls), we are all at the mercy of the terms of our insurance contracts and the goodwill of our healthcare providers. I think the quoted poster's point (and mine in my reply to that post) was that there are some things you can do to minimize the risk of this happening, the most important of which is knowing the terms of your contract with your insurance company.

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Re: Does Insurance Have to Pay an Out-of-Network Ambulance Bill in Full?

Postby sawhorse » Thu Apr 20, 2017 1:47 pm

Rupert wrote:I think the quoted poster's point (and mine in my reply to that post) was that there are some things you can do to minimize the risk of this happening, the most important of which is knowing the terms of your contract with your insurance company.

Good point. I would add that it's important to carefully review the terms every year and not assume that what was covered before is still covered, what didn't require a referral before still doesn't, etc.

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Re: Does Insurance Have to Pay an Out-of-Network Ambulance Bill in Full?

Postby littlebird » Thu Apr 20, 2017 2:10 pm

EagertoLearnMore wrote:EMS Subscription

Some towns offer yearly subscription services that you PAY to belong to the local EMS service. You can select individual, couple, family. BUT -- no visitors, only residents of the home.

Then if you or member needs to use the ambulance they will accept whatever your insurance is willing to pay. Yes, they balance bill, but you call and say look at subscription and difference from insurance payment is forgiven.


My local Fire Dept/EMS works like this based on your status as a taxpayer; no subscription involved, but again, this is only for emergency service.

For non-emergency transfers between facilities and from facility to home, there is a whole industry called "Medical Transport". They can deal with gurneys, wheelchairs and ambulatory patients. They are not medically certified, but generally competent and helpful. Many years ago, when Medicare first came into being, it paid for this service. That ended after it became a bit of a scam, with everyone "needing" it to go to a doctor visit. Nowadays, the patient pays for it, but in my experience, it been only $65-110, depending on the time of day and my spouse's degree of need for assistance (1 tech, 2 techs and a gurney, etc.). The hospital social worker should be able to help with this. Docs may not even think of it.

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Re: Does Insurance Have to Pay an Out-of-Network Ambulance Bill in Full?

Postby LadyGeek » Thu Apr 20, 2017 3:27 pm

This thread is now in the Personal Finance (Not Investing) forum (insurance).

A few posts are straying towards a general rant about insurance reimbursement payments. As a reminder, please remain focused on the OP's question.
Kennedy wrote:A family member was driven to Hospital A in a private car and was then was admitted. They were transferred to Hospital B the next day. The doctor recommended the transfer since Hospital B had a higher-level care that the family member required.

The transfer was via an ambulance operated by a small town. The ambulance company was not in-network with our insurance company.

When the EOB arrived, our insurance had paid about 50% of the bill, and there was a note stating that if the City (ambulance) billed us for the difference, we were to contact a third party group that provided fair estimates on ambulance bills. Well... the City billed us for the balance. We called the third party who tried to get the City to accept the lower rate already paid by the insurance. The City refused and is billing us, still, for the balance.

Any thoughts? I would assume that if the ambulance did not tell us they were out of network and what the fee would be, they could only charge a "reasonable" fee. I would further assume that the reasonable fee would be determined by the independent third party. After all, what's to stop the ambulance company from billing us any amount at all of their choosing without disclosure?
To some, the glass is half full. To others, the glass is half empty. To an engineer, it's twice the size it needs to be.

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Re: Does Insurance Have to Pay an Out-of-Network Ambulance Bill in Full?

Postby toofache32 » Thu Apr 20, 2017 4:54 pm

sawhorse wrote:
When you're in the in network hospital, what happens if the hospitalist or other doctor consulted (radiologist, etc) is out of network? As both the doctors and nurses work in shifts, the nurses might not be able to tell you who is going to be the hospitalist checking on you, and I'm not sure what you can do anyway.


I'm that doctor. I'm not in-network with any medical insurance but both my hospitals require me to take call. Most hospital bylaws require this of their doctors who have admitting/surgical privileges at that hospital.

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Re: Does Insurance Have to Pay an Out-of-Network Ambulance Bill in Full?

Postby sawhorse » Thu Apr 20, 2017 6:46 pm

toofache32 wrote:
sawhorse wrote:
When you're in the in network hospital, what happens if the hospitalist or other doctor consulted (radiologist, etc) is out of network? As both the doctors and nurses work in shifts, the nurses might not be able to tell you who is going to be the hospitalist checking on you, and I'm not sure what you can do anyway.


I'm that doctor. I'm not in-network with any medical insurance but both my hospitals require me to take call. Most hospital bylaws require this of their doctors who have admitting/surgical privileges at that hospital.
So do you tell patients you're not in network and give them an upfront cost, or do they receive a surprise bill?

toofache32
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Re: Does Insurance Have to Pay an Out-of-Network Ambulance Bill in Full?

Postby toofache32 » Thu Apr 20, 2017 7:07 pm

sawhorse wrote:
toofache32 wrote:
sawhorse wrote:
When you're in the in network hospital, what happens if the hospitalist or other doctor consulted (radiologist, etc) is out of network? As both the doctors and nurses work in shifts, the nurses might not be able to tell you who is going to be the hospitalist checking on you, and I'm not sure what you can do anyway.


I'm that doctor. I'm not in-network with any medical insurance but both my hospitals require me to take call. Most hospital bylaws require this of their doctors who have admitting/surgical privileges at that hospital.
So do you tell patients you're not in network and give them an upfront cost, or do they receive a surprise bill?


Depends on the situation. Surprisingly, it's worse when I tell them up front. I don't want to derail this thread.
Last edited by toofache32 on Fri Apr 21, 2017 8:30 am, edited 1 time in total.

teen persuasion
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Re: Does Insurance Have to Pay an Out-of-Network Ambulance Bill in Full?

Postby teen persuasion » Fri Apr 21, 2017 7:55 am

littlebird wrote:
EagertoLearnMore wrote:EMS Subscription

Some towns offer yearly subscription services that you PAY to belong to the local EMS service. You can select individual, couple, family. BUT -- no visitors, only residents of the home.

Then if you or member needs to use the ambulance they will accept whatever your insurance is willing to pay. Yes, they balance bill, but you call and say look at subscription and difference from insurance payment is forgiven.


My local Fire Dept/EMS works like this based on your status as a taxpayer; no subscription involved, but again, this is only for emergency service.


My DH was a volunteer EMT with a local fire company; there was a local volunteer ambulance service that they worked with as well. When a call came in, the for-profit ambulance service that served the larger metro area would attempt to respond - if they arrived before the volunteer service, they got the business. I can see both sides here - the volunteer service had limited resources, so if they were already busy on another call, the for-profit service was needed to cover, and in a true time-is-of-essence emergency you want them to respond immediately. Most of the time, however, they really could defer to the volunteer service rather than swooping in to grab the fee.

As for hospital transport - when DH needed to be transferred to a different hospital his EMS buddies were literally on hand and visiting him after a call. They offered to transport him, but the hospital insisted they had a contract with the for-profit service, and COULD NOT allow anyone else to transport patients. Eventually the doctor put his foot down and said "Let his buddies transport him", in essence telling staff to look the other way and break the rules. The for-profit service was definitely objecting.

Rules are very local - your state may ban balance billing, or allow it. The hospital may have a contract as in our case, or there may be competition. The OP needs to research his local situation, that's the only one that counts here.

toofache32
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Re: Does Insurance Have to Pay an Out-of-Network Ambulance Bill in Full?

Postby toofache32 » Fri Apr 21, 2017 8:55 am

teen persuasion wrote:
As for hospital transport - when DH needed to be transferred to a different hospital his EMS buddies were literally on hand and visiting him after a call. They offered to transport him, but the hospital insisted they had a contract with the for-profit service, and COULD NOT allow anyone else to transport patients. Eventually the doctor put his foot down and said "Let his buddies transport him", in essence telling staff to look the other way and break the rules. The for-profit service was definitely objecting.

Rules are very local - your state may ban balance billing, or allow it. The hospital may have a contract as in our case, or there may be competition. The OP needs to research his local situation, that's the only one that counts here.


"The doctor" rarely has this kind of authority anymore. The doctor's boss is a nurse with a clipboard and makes those decisions without the doctor.


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