Finding Ulysses

The title above is a direct quote from Eric Dodge who represents MedEx, the third party billing company, that the Village of Trumansburg is now using to bill residents for ambulance calls.

I used to think that I was safe, and that the uninsured and the underinsured, were the only ones put at risk by the new ambulance billing policy.  But I’ve heard that it is common for private insurers to deny coverage for a variety of reasons, so I wrote a few emails to Brian Snyder (the manager of our EMS) and Eric Dodge to get their opinions on whether or not those of us that are well insured might also be at risk of getting stuck with a large bill, and therefore be reluctant to call for help when needed.

I attached a copy of the pertinent section of description of benefits from my own policy - (Empire Plan – subsidiary of United Health – the largest private insurer in the country)

Here is the email exchange,

Brian and Eric,

When I read the attached description of benefits, it seems to me that the Empire plan has left themselves some wiggle room that might allow them to refuse coverage.  In order to feel certain that I would be covered I would need a law degree, with a focus on insurance, and complete legal definitions of,

“emergency condition”

“medically necessary non emergency transportation”

“licensed ambulance service”

“local professional ambulance”

“voluntary ambulance”

Since our EMS is partially volunteer, and partially taxpayer funded, I suspect that a clever lawyer in the employ of Empire, might be able to find a way to avoid paying.  Perhaps, they would graciously donate up to $50.

Please clear up my confusion.

Thank You

Allen Carstensen

This is a multi-faceted question, and I will do my best to try and answer it!

All the insurances leave themselves “wiggle room” in regards to various reasons to deny claims. With the private insurances, we have dealt with this rather well for many years. They have always rejected claims for medical necessity, having the term “Volunteer” in their name, wearing their socks on the wrong feet, etc. We appeal every denial that is “workable”. The NYS GML’s do allow for any ambulance (except for Fire based units) to bill for service. We point this fact out to every insurance provider that uses the “Volunteer” excuse.

Medical necessity is a bit trickier, but still manageable. There are always going to be some of your responses that will be rejected for lack of medical necessity, and that will be so weakly documented, that we just will not be able to appeal them. It happens, especially in a State that mandates EMS transport patients that insist upon using the ambulance for the most minor issues. Mostly though, our compliance procedures allow us to bill the claim appropriately to Medicare ( and the private insurances as well) for a denial, which then allows us to bill the patient. It’s the proper (but not popular) way to do it. And eventually, it should slow down the number of calls that you receive that are unnecessary.

Even with all of these factors that insurance providers use to deny claims, MedEx is still averaging a calls paid rate of over 82%. That’s well above the industry average of 65%.

I hope this helps answer the questions Brian. Please let me know if I missed something!

Eric