|Date:||June 13, 2016|
When Sarasota resident Lisa Dunlap fainted, she didn’t know she’d be on the hook for more than just her hospital bill.
Her husband called 911 from their Palmer Ranch home and an ambulance quickly arrived to take her to Doctors Hospital. Doctors there treated her and discharged her. Then the bills arrived.
Though Dunlop has health insurance and knew she’d have a co-pay for her ambulance ride, she received a second bill from the Sarasota County Fire Department for $204.33. It turned out the county’s ambulance service is not in her Florida Blue insurance network, so in addition to her $350 co-pay, she had to pay the difference between what her insurance company paid, $118.67, and what the fire department charged, $673.00.
When she dug further, she found out that Sarasota County does not contract with any health insurance companies. Neither does Manatee County.
Sarasota and Manatee are not unusual — in most states, both government-run and privately operated ambulance services do not participate in health insurance networks. The reality of surprise ambulance bills is a common problem for people, regardless of their insurance coverage status.
But governments point out that the ambulance charges are not a way to make a profit. As with all other areas of health care, costs for paramedic care and ambulance service are increasing rapidly, and local tax revenue simply is not enough to cover those costs. For instance, as Manatee County was dealing with a growing heroin crisis recently, the price of the antidote drug Narcan doubled overnight. The service had to absorb that cost, along with price increases in dozens of other lifesaving medications, saidPaul DiCicco, the county's acting Emergency Medical Services chief.
The counties also point out that insurance companies often offer rates below their cost of doing business and require them to comply with detailed paperwork requirements and low reimbursement rates that would force ambulance services to operate like health care companies. This contrasts, for instance, with public hospital districts such as the Sarasota County Public Hospital District, which are equipped to code each patient bill to comply with the complex requirements of dozens of insurance companies. County ambulance services are not.
The reality of rising health costs and insurance complexity has forced thousands of local governments, including Sarasota and Manatee counties, into the business of health care.
But caught in the middle are the patients, who are in no position to question an ambulance company when they’re unconscious or facing a life-threatening health emergency.
“What on earth do you do where you’re in such pain that you’re not thinking?” asked Ruth Lando, who dislocated her elbow when she fell in a Sarasota parking lot and got a surprise ambulance bill. “Asking about insurance coverage was the furthest thing from my mind.”
In Sarasota County, the fire department is the sole provider of 911-dispatched ambulance service for everyone in the city of Sarasota, Venice and unincorporated areas of the county. The cities of North Port and Longboat Key operate their own ambulance services, which are also run by their respective fire departments.
But some Florida counties and cities work with private ambulance companies to offer ambulance services. For instance, in Orlando, Miami and in areas on the Treasure Coast, a private multi-national ambulance company, Falck USA, operates non-emergency ambulance service, such as hospital-to-hospital or hospital-to-nursing home transport. In other states, the same company operates 911 dispatch services.
Falck and other private companies have the billing infrastructure to contract with insurance companies, and sometimes do, but Falck largely depends on the rates that insurance companies are willing to pay for the ambulance service, said Charles Maymon, regional CEO for Falck.
"Sometimes, we’ll be approached by an insurance company and they quote us a reimbursement rate and we have to say, 'Thanks, but no thanks, we can’t do it for that rate,'" Maymon said. "That’s just financial reality."
For their part, health insurance companies, including Florida Blue, say they want to work with ambulance providers but providers don't want to contract with them.
"Florida Blue makes a good-faith effort to contract with ambulance companies operated by both government entities and private firms; however, most ambulance service providers choose not to contract with any health insurer," Florida Blue spokeswoman Christie Hyde DeNave said in a written statement. "Because of this, claims from those ambulance companies are treated like other out-of-network provider claims and reimbursed at our non-participating provider rate. In many cases, ambulance companies will later bill the member for the remaining amount charged (also known as “balance billing”)."
Without an insurance contract, ambulance services must bill patients to cover their costs of service.While the millions collected, for instance, from Manatee County patients helps fund the county's $14 million budget for ambulance operations, it is not a money-making enterprise, DiCicco said. It's more akin to a public utility.
"The best way to look at it is just like how you pay your water bill," DiCicco said. "Your property taxes pay for the infrastructure of water pipes, but as soon as you turn on the water, you pay a user fee. That's how it is with the ambulance."
Both Sarasota and Manatee Counties say they are very willing to work with people who can’t pay their bills and often write off the debts of people they cannot track down.
“The point is to cover our costs, we’re not a profit-making business at all,” said Sarasota County Assistant Fire Chief Rod Van Orsdal. “We just want to continue to provide the highest level of care we can. There’s no way we can stay in business without charging.”
Not limited to ambulances
Surprise medical bills don’t just come from ambulance providers. Emergency rooms and hospitals are other major sources of them. This happens most often when individual doctors who treat a patient are not in the patient’s insurance network, even though the medical facility is. For example, a patient chooses an in-network hospital for surgery, but the anesthesiologist is not in their insurance networkand sends them an unexpected bill.
While this is a major problem nationally, Florida lawmakers in their latest session passed a law to protect consumers from these out-of-network bills. Beginning July 1, if a patient goes to an in-network facility and is treated by an out-of-network provider, the patient is only responsible for paying the in-network rate.
The new law does not apply to ambulances. But the situation with ambulances is the same as with hospitals or emergency departments, said Chuck Bell, a program director at Consumers Union, a consumer advocacy group.
“In an emergency, the patient has no choice over which ambulance company to use, and most patients would assume protection from surprise bills is why they’re purchasing insurance in the first place,” Bell said.
“I think most consumers are willing to play by the rules of choosing a health provider who is in-network with their insurance company, but when it comes to ambulances and emergency, there’s really no time for comparison shopping,” Bell said.
This isn’t news to Van Orsdal and his team in Sarasota County. But divulging too much information about charges makes Van Orsdal worry that it might make people reluctant to call 911.
“There are emergencies, such as a stroke or a heart attack, where response time is everything,” he said. “For people to be focused on the idea that they don’t want an ambulance bill and to have that defer them from contacting 911, that’s horrible, that’s not what we want to do.
"We have a billing company that tries to work diligently with people to get the bill where it’s affordable, even going as low at $5 per month with no interest,” Van Orsdal said.
Dunlap, the fainting victim, says she feels lucky that she can afford to pay the unanticipated charge and she’s grateful to know what her charges will be if she has to call an ambulance again. But she, like Van Orsdal, worries about people who don’t have the extra money for the bill and might hesitate to call in an emergency.
“Their spouse might choose to drive at night when maybe they shouldn’t, or maybe they’ll see if they can ride out the pain,” Lisa said. “It could be really scary.”
Sarasota County ambulance charges
NOTE: Some insurance companies will pay a portion of these charges. Check with your insurance company to find out how much you'll owe if you call an ambulance.
What to do if you get a surprise ambulance bill
■ Appeal the out-of-network bill with your insurance company. Ask them to reprocess the bill to see if they missed something.
■ File a claim with the state insurance commission to let them know about the out-of-network charge.
■ Ask the ambulance company or local government for a lowered payment or a payment plan. Tell your HR director or whoever is responsible for purchasing your insurance, so they know about the issue with the insurance policy.