Even with insurance, that EMS bill could cause sticker shock

April 13--Sandy Bayne was two months pregnant and at an Austin pharmacy last fall when her nose suddenly began to bleed profusely. She called her physician father, and when the bleeding wouldn't stop, she took his advice to call 911.

By industry standards, her $867 ambulance bill was not especially steep. But Bayne, who is covered by Blue Cross Blue Shield of Texas and worked as a health care lawyer for 11 years, was amazed to discover she was on the hook for the entire amount.

Even the savviest consumers are often unaware that they might have to shoulder a large share of their ambulance bill.

Austin-Travis County Emergency Medical Services is the exclusive emergency ambulance provider in the county. Whatever portion of the bill is not covered by private insurance, the patient is asked to pay. EMS providers in Williamson and Hays counties do it the same way -- as do many municipal EMS agencies nationally.

That practice of balance billing is widely criticized by consumer advocates who say it's unfair because emergency patients have no way to seek a lower-cost ambulance service when they call 911.

While the federal government forbids ambulance companies from balance billing patients covered by government payers, such as Medicare or Medicaid, consumers who buy private insurance are treated differently by EMS.

In Tarrant County, the same ambulance ride would have cost Bayne nearly $1,500.

"When you call 911, you get no say in who shows up," said Stacey Pogue, a senior policy analyst with the Austin-based Center for Public Policy Priorities. "That scenario is exactly why you need protection in an emergency. You have a 100 percent chance in Austin of getting an out-of-network ambulance ride. I think that would be somewhat shocking to a consumer.

"Balance billing can be crippling for families."

Few states provide consumer protections for emergency ambulance billing, Kaiser Family Foundation data show.

After a four-year process, Texas put new rules in place last year that, in effect, have insurers paying a bit more and consumers paying less, Pogue said. "Things were worse before the rules, but it doesn't change the fact that people are still getting big and unexpected bills in emergencies," she said.

In the emergency room last fall at Seton Medical Center Austin, Bayne said her nose stopped bleeding soon after she arrived. She was quickly discharged. Then came the EMS bill.

Bayne, who is 35 and the married mother of two other children, called EMS and her insurer to object. She discovered that, at the time of her emergency, Oct. 30, she had not satisfied her insurance policy's $2,500 deductible. But even if she had, Blue Cross told her she still would have been responsible for more than half of the bill -- $461, Bayne said.

'Caught in the middle'

Insurance payments vary widely based on individual policies and the amount of service a patient receives on the ride to the hospital.

Austin-Travis County EMS, which transports more than 75,000 patients a year to local hospitals, will send a bill to private insurers on behalf of their covered patients. But unlike going to a hospital or a doctor in your health plan's network -- and likely being responsible for a smaller share of the overall bill -- EMS does not have contracts with private insurers such as Blue Cross.

Further, Austin-Travis County EMS does not negotiate payment amounts with consumers, even though some people will never be able to pay their bills, making them uncollectible. The county's base rate is $815, plus $12.50 per mile. EMS officials said they will place consumers needing help on a payment plan, with some paying as little as a few dollars a month -- for years.

Negotiated rates for medical care generally entitle private insurance companies to a substantial cut in cost. But EMS providers have no incentive to negotiate discounted rates with insurers, said Douglas Hooten, president of the Texas EMS Alliance and of the . That's especially true when there are no other 911 competitors in a community.

The money to cover the service "has got to come from somewhere," he said.

Newly insured people under the Affordable Care Act represent a whole new group of people poised to confront balance billing for ambulance services, Pogue and others said.

"I think people who have insurance very comfortably think, 'Because I have insurance, I will be covered,'" said Bayne, who has since paid her bill in full.

So that consumers don't get "caught in the middle," EMS providers and insurance companies should get together and negotiate a fair cost for ambulance service, said Kevin Lucia, a senior research fellow at the Center on Health Insurance Reforms at Georgetown University.

"Balance billing is really an issue between the provider and the insurer, and the consumer is used as a pawn," Lucia said. "Consumers go to hospitals that are in network and they don't expect to be balance billed. The person having an emergency is not in the position of asking whether the doctor or ambulance is in network."

Even if an emergency patient were to ask about the cost of an ambulance ride before getting in, Travis County EMS personnel are not likely to have answers. They don't have insurance information nor are they in any position to discuss costs, EMS Chief of Staff James Shamard said.

"We're dealing with folks at one of the worst times in their lives," he said. "It's about taking care of patients."

People with insurance are advised to find out before they need an ambulance how much of the cost is covered. They are likely to face far steeper charges once they get to the hospital. Emergency care is among the costliest of medical services.

Paying for the rest

Austin-Travis EMS collects about $20 million in ambulance fee revenue a year -- about a third of the $59.9 million budgeted for the service. Most of the rest comes from the city and county.

At the same time, however, Travis County taxpayers who need an ambulance help pay again for EMS. They also subsidize the emergency ambulance costs of out-of-town visitors who call 911.

If not for that taxpayer money, Austin-Travis County EMS bills would likely be much higher. MedStar Mobile Healthcare, which is the exclusive 911 provider in Fort Worth covering 15 Tarrant County cities, doesn't get any taxpayer support, and its fees start at $1,485, said Hooten, MedStar's executive director.

Austin-Travis County EMS said the costs to taxpayers would rise further if it had contracts with insurers.

"Private insurance has a vested interest in increasing the company profit line regardless of the impact on the cost of readiness," having the service available, 24/7, officials said in a statement. "If the city entered into contracts with private insurance companies, the cost of use would shift to the general taxpayers by increasing the cost of readiness."

Like MedStar, Austin-Travis EMS has a program designed to reduce the number of unnecessary EMS transports -- and uncollectible bills -- by sending paramedics to help fit callers into social and other services when an ambulance is not warranted.

Austin-Travis County EMS collects about 35 cents on the dollar for its emergency calls, mostly because of uncollectible bills.

"Like all of health care, there is a lot of cost-shifting," Hooten said. "Our bills would be about $400 if everyone paid. The way it is, those that can pay, pay. And they also pay for the ones who can't."

Said Bayne: "I can afford this bill, but for people who are struggling or a single mom, she may be looking at a $1,000 bill."

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The Texas Department of Insurance receives complaints about insurers and has a help line for consumers in the state. The toll-free number is 800-252-3439. The agency also offer tips for dealing with balance billing and other matters at http://www.tdi.texas.gov/consumer/cpmbalancebilling.html.

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