State Rep. Dale Folwell filed legislation last week that he said fixes a flaw in the State Health Plan that could allow for fraud against the state and municipalities that provide ambulance service.
The flaw: Plan members are cut a check for the cost of an ambulance ride when the provider is not part of the plan's network.
The check is in the member's name, so if he or she pockets it, the ambulance service is out of the money. Each trip costs roughly $500.
At least 24 municipal services are not in the plan's network, including those serving Durham, Forsyth, Mecklenburg and Randolph counties, Folwell said.
Folwell presented anecdotal evidence of ambulance riders failing to pay for the service.
In one case, a public school retiree from Forsyth County requested 22 ambulance trips last year, collecting nearly $12,500 from the health plan.
The county has yet to be reimbursed for the ambulance service.
Folwell's legislation would require all checks that the plan issues for ambulance service be directly payable to the service, or require the checks be co-payable to the plan member and the ambulance service. He said the change would ensure that the plan member could not pocket the money.
"If we can change the behavior of the people who may be unnecessarily riding an ambulance to collect a check, we save the state and we save the counties," Folwell said.
Most insurance companies pay ambulance services directly for trips, whether providers are in or out of the insurer's network.
A provider within an insurer network has agreed to charge a specific rate for services. Blue Cross and Blue Shield of North Carolina, which processes claims for the plan, reimburses directly only to providers within its network.
Rep. Larry Hall, a Durham Democrat, is among the primary sponsors of Folwell's legislation.
Hall said Durham County has had difficulty collecting from some ambulance users. He did not know whether any are among the roughly 667,000 state employees, teachers and retirees on the State Health Plan, but he said it made sense to prevent someone from cashing the check and keeping the money.
"Even though they received the service at a critical time, they may not decide to pay it," Hall said.
Folwell, a Forsyth County Republican, said he discovered the flaw in the plan when his son suffered a broken femur and needed an ambulance ride. The plan sent the check for the ambulance ride to Folwell.
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