Calling 911 for an ambulance? Check your deductible first [The Palm Beach Post, Fla.]

Sept. 29--BOYNTON BEACH -- Penny Farrow called 911. An ambulance took her to a hospital where she was treated for a heart problem. She began to feel better. Then she got the bill.

The state's largest health insurer, Florida Blue, said Palm Beach County Fire Rescue was an "out of network" provider under her plan. So she owed about $600.

Few people calling 911 are in a position to ask about deductibles and fees, let alone shop around for a better deal. And for some consumers like Farrow, it's more than an arcane public-policy puzzler in the modern health care world. It's a punch to the pocketbook they never saw coming.

"It is truly amazing that someone calling 911 in the middle of the night has to worry about whether the dispatcher is sending someone that is not in the network," said Farrow, who lives in a suburb of Boynton Beach. "And how can Palm Beach County Fire Rescue, a huge provider in a huge county, not be in the network of a major company like Blue Cross/Blue Shield? No wonder Americans are furious at insurance companies. It is unconscionable."

Fire-rescue officials warn taxes might have to go up if they join insurer networks and have to negotiate prices.

The Affordable Care Act, the federal health care law, requires insurers to bill consumers for emergency-room services as if they were in network. The law says if such services "are provided out-of-network, the cost-sharing requirement (expressed as a co-payment amount or co-insurance rate) is the same requirement that would apply if such services were provided in-network."

But the requirement does not expressly cover everything -- such as the ambulance ride before the patient gets to the emergency room, said Jeffrey Cohen, a Delray Beach attorney who is board-certified in health law. He says in some cases, industry changes are "driving co-pays and deductibles up."

Overall, the Affordable Care Act lowers costs for consumers in many ways, a spokesman for the U.S. Department of Health and Human Services said. Besides the protections on emergency services, certain preventive services such as cancer screenings come at no additional cost to the patient. And Florida consumers received $124 million in rebates from insurers under rules that limit spending on administrative and other costs, the spokesman said.

But with 911 medical transport service, consumers can in effect be asked to pay three times -- through taxes and insurance premiums as well as out-of-pocket costs the insurer does not cover.

That's a public health concern, as Farrow sees it, because consumers on a tight budget or fixed income might think twice about calling 911 if they fear the cost. Paying $100 or $150 out of pocket for an ambulance trip is one thing, but facing $600 or more on top of other potential costs is another when deciding what to do in a scary and uncertain medical situation.

Farrow appealed to Florida Blue for help at its Boynton Beach customer office. Florida's largest health insurer with 4 million customers, the company reviewed the charge but concluded it was acting appropriately. Under Farrow's policy, a significant deductible applied with an out-of-network provider, officials said.

"Many emergency transportation companies -- especially county-based operations -- make the business decision not to contract with insurance companies," said John Herbkerson, Florida Blue's senior director of external communications in Jacksonville. "Of course, policies and coverage varies per individual, but the majority of insurance policies do provide in-network coverage for emergency transportation by ground, air and water when deemed medically necessary, whereas not providing such transportation would result in harm to the member."

Some insurers say they generally treat emergency ambulance service as if it were in-network.

"Cigna covers emergency-related ambulance services at the in-network benefit level, regardless of whether the ambulance service has a contract in place with Cigna," company spokeswoman Amy Turkington said.

So does Humana: "For emergency medical services, Humana covers emergency ambulance transportation at the in-network benefit level for our health plan members regardless of whether the ambulance service is within or outside Humana's provider network," spokesman Mitch Lubitz said.

Industry officials note employers who self-insure may make their own choices about what's covered and hire an insurance company to administer the plan.

After an inquiry from The Palm Beach Post, Palm Beach County Commissioner Steven Abrams asked county fire chief Steve Jerauld why Palm Beach County Fire Rescue would seek not to be in an insurer's network.

Answer: Taxes might have to go up.

"Becoming an 'in-network' provider means a negotiated payment that will likely result in a decrease in revenue and will negatively affect our ability to maintain the current millage rate," Jerauld said in an email.

Projected transport revenues for the county service are $19 million this year, he said.

"If transport revenues are reduced, the obligation to each property taxpayer in Palm Beach County will increase," Jerauld said.

County commissioners authorize the fire-rescue department's budget and fees. County ambulance fees range from $530 to $690 plus $10 a mile, a spokesman said. At a June 26 budget workshop, the board "strongly encouraged Fire Rescue to maximize the transportation fee collections in the face of budget deficits and declining ad valorem revenues," Jerauld said.

A caller's location typically determines who responds to a 911 call, and it could be a city's service. West Palm Beach officials said their 911 service generally does not enter into contracts with insurers.

The city's fire-rescue service charges $700 plus $12 a mile, or $750 plus mileage in more complex cases, without separate charges for such things as medications or IV, city spokeman Elliot Cohen said.

The city's fire-rescue unit issues the same bill regardless of the patient's financial status, Cohen said, and it's up to insurers to decide what portion the consumer pays.

"Our fire-rescue's commitment is to always provide whatever help is needed in any emergency, regardless of a person's insurance situation," Cohen said. "When you call 911, we will always be there, and we will always do whatever it takes to help. That's our number one mission and commitment."

But insurance industry groups say it's hard to hold down premiums and out-of-pocket costs if there is little to slow down price increases from out-of-network providers, whether for ambulance service or a host of other things.

"What we've seen happen across the county is some providers refuse to contract with a health plan and then want a blank check to charge whatever they want for the service," said Robert Zirkelbach, spokesman for America's Health Insurance Plans, a Washington group representing large health insurers. "Unfortunately, patients are getting stuck in the middle, and that shouldn't happen. But the focus can't be just on what is covered. We also need to focus on what providers are charging."

Meanwhile, consumers like Farrow can feel like they're coming out on the losing end in a tug of war.

"It's abusive," Farrow said. "It's not right."

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