Think the ER was expensive? The ambulance ride could be more

New York TimesDecember 7, 2013 

Kira Milas has no idea who called 911, summoning an ambulance filled with emergency medical technicians. Milas, 23, was working as a swim instructor for the summer and had swum into the side of the pool, breaking three teeth.

Shaken, she accepted the ambulance ride to Scripps Memorial Hospital in La Jolla, Calif. The paramedics applied a neck brace as a precaution.

A week later, she received a bill for the 15-minute trip: $1,772.42. Although her employer’s workers’ compensation will cover the bill, she still was stunned at the charge. “We only drove nine miles, and it was a non-life-threatening injury,” she said in a phone interview. “I needed absolutely no emergency treatment.”

Thirty years ago, ambulance rides were generally provided free of charge, underwritten by taxpayers as a municipal service or provided by volunteers. Today, like the rest of the health care system in the United States, most ambulance services operate as businesses and contribute to the country’s escalating medical bills. Often, they are a high-cost prequel to expensive emergency room visits.

Although ambulances are often requested by a bystander or summoned by 911 dispatchers, they are almost always billed to the patient involved. And the charges, as well as insurance coverage, range widely, from zero to tens of thousands of dollars.

“There are a significant numbers of patients who have no coverage for this, and the number of self-pay patients has climbed” since the recession, said Jay Fitch, president of Fitch and Associates, the largest emergency medical services consulting firm in the United States.

What is more, since ambulance companies typically collect only 30 to 40 percent of the amount they bill, they often try to charge more for patients with insurance and those who can pay, Fitch said.

Part of the inconsistency in pricing stems from the fact that ambulance services are variously run by fire departments, hospitals, private companies and volunteer groups. Some services are included in insurance networks, others not.

“There’s a saying that if you’ve seen one emergency medical system, you’ve seen one emergency medical system – no two are alike,” said Dr. Robert E. O'Connor, a vice president of the American College of Emergency Medicine and chairman of the department at the University of Virginia. Charges and payments, he said, “are all over the place.” Fire departments, which don’t charge for driving to fire alarms, do charge for ambulance runs.

Some coverage required

In such a fragmented system, it is hard to know how much high-priced ambulance transport contributes nationally to the country’s $2.7 trillion health care bill. And total out-of-pocket expenditures by individuals are hard to tally.

But Medicare, the insurance program for the elderly, does tabulate its numbers and has become alarmed at its fast-rising expenditures for ambulance rides: nearly $6 billion a year, up from $2 billion in 2002.

The Affordable Care Act requires policies to include some coverage for emergency care as an essential benefit, including ambulance transport. But the ambulance ride and the care are billed separately. Many Silver plans – a lower-tier plan – require patients to pay an initial copay of $250 for the emergency room and $250 more for the transport, for example.

Every insurance plan evaluates ambulance rides differently for coverage, with many seeking to determine whether the service was really needed – a true “emergency.”

That determination can be highly subjective. Some will grant coverage if the destination was an emergency room, regardless of the patient’s status, but others may require admittance to the hospital as evidence that the condition was serious. “Insurers will generally cover if you had good reason to believe there was a serious threat to your life or health,” said Susan Pisano, a spokeswoman for America’s Health Insurance Plans, an industry group.

But when an ambulance arrives, sick patients or injured people like Milas often feel they have little choice but to get in, unaware of the potential price tag.

Two blocks, $900

If an emergency call comes to 911, dispatchers decide which ambulance to send, depending on proximity. Most ambulance companies bill according to the level of skill of the team on board, rather than the medical needs of the patients they collect. A team capable of administering Advanced Cardiac Life Support costs more than one with only basic first aid training.

Distance rarely counts for much, although a small mileage charge is added to the fee. Some companies even charge hundreds of dollars extra if a friend or relative rides along with an injured patients.

This fall, Joann Freedman went to an urgent care center near her home in New York City with a bad headache and a fever. The doctor recommended that she go to a hospital for further evaluation and offered to call an ambulance.

“I could have walked, but I’m feeling crummy so I think, ‘OK, why not?’” she recalled.

The two-block ride was billed at $900, and she has not yet learned what her insurer may ask her to pay.

“It was crazy,” she said. “All they did was put a paper mask on me so I wouldn’t infect anyone else.” Freedman had a spinal tap at the hospital and was admitted for a few days. Nonetheless, she said, for $900, the next time, no matter how ill she will walk up the hill or take a cab.

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