Air ambulance companies overly aggressive in pursuing payments in Missouri, state says

Jan. 09--Air ambulance companies take advantage of sick or injured Missourians with bills that average $20,000 a trip despite insurance coverage, according to a state report released Tuesday.

People with private health insurance who are airlifted to hospitals across the state also face predatory collection efforts, the Missouri Department of Insurance, Financial Institutions and Professional Registration says in the report that follows media reports and legislative pressure over the high costs of air ambulance flights.

One Missourian suffered a traumatic eye injury after being kicked by a horse and was charged $25,000 for an air ambulance flight. Another person with encephalitis, or life-threatening brain swelling, received a bill for $100,000 because the insurance claim for air transport was denied. An insurance company paid $4,500 of a $27,000 airlift bill for someone with open bone fractures after a car accident, according to the state's findings.

Hundreds of residents have been sued or experienced garnished wages and liens on their homes in air transport companies' attempts to collect on the bills, the report said.

"It's a tremendous financial burden on Missourians and a significant eye-opener for us," said Angela Nelson, director of the department's insurance market regulation division.

The report follows a 2018 Post-Dispatch investigation that found a lack of in-network air ambulance providers resulting in dozens of families with hefty insurance bills. The problem lies in "balance billing," when providers and insurance companies do not have pricing agreements and the air ambulance company charges the patient the portion of the bill that insurance didn't cover.

"When air ambulances choose not to participate in networks ... they charge whatever rates they like. The consequence is patients receiving surprise, unexpected medical bills that can often break the bank," said Cathryn Donaldson of the trade group America's Health Insurance Plans.

The state insurance department found:

* Private insurance companies covered $13.1 million of the total $25.7 million Missourians were billed for air ambulance services in 2017.

* Some Missouri patients with private insurance have received air ambulance bills higher than $100,000.

* Four air ambulance companies have filed 427 lawsuits or liens against Missouri patients in pursuit of payments since 2012.

* The state department has received 128 complaints or inquiries about insurance coverage for air ambulance services since 2013.

* Patients have recovered more than $560,000 in 23 cases where their bills were disputed.

* Without rate agreements and a lack of oversight power by the state for air ambulance companies, there is "no one to monitor what they're charging and how," Nelson said.

* There may be some relief ahead, at least for Anthem health insurance plan holders. Last summer, Anthem signed coverage agreements with two of the 13 emergency air ambulance companies in Missouri -- Air Evac Lifeteam of O'Fallon, Mo., and Air Methods, owners of ARCH Air Medical Service in St. Louis. The two companies handled about 40 percent of the 10,558 air ambulance transports in the state in 2017, according to the Missouri insurance department.

"Having air ambulance transport companies work with and negotiate with insurance companies provides consumers with the best protection available, the consumer is held harmless for any amount beyond the negotiated rate," Nelson said.

In-network providers are guided by contracts set by Medicare and Medicaid. Low reimbursement rates from the government insurance plans have led to air ambulance companies' attempts to recoup their costs via private insurance companies, according to the state report.

Medicare reimburses air ambulance flights up to $6,404 plus mileage costs, while Medicaid pays out $2,254 plus mileage. Private insurers paid out an average of $23,087 on charges of $41,321 a trip in 2017, the state's data show. Without rate agreements, the patient is on the hook for the difference.

Representatives of Air Evac Lifeteam and Air Methods could not be reached Wednesday for comment.

State insurance officials said one goal of the report was to inspire state and federal legislators to craft better consumer protections. Congress passed legislation in October, pushed by then- Sen. Claire McCaskill, D-Mo., to establish an advisory committee on air ambulance practices.

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