The ambulance chased a patient in the collections

In retrospect, Peggy Dula said she shouldn’t have taken the ambulance. She was the least injured of the three siblings who were in a car when she was hit by a van last September. Her daughter had even offered to come to the scene of the accident and pick her up.

Jim Martens, 62, and Cynthia Martens, 63, Peggy’s brother and sister, were more seriously injured and were heading to hospital in separate ambulances. Peggy, 55, was told it would be a good idea for her to get checked too. So she accepted a ride with a third ambulance team.

When the wreckage happened, the siblings were going to see the horses Peggy’s daughter trains in a barn west of Peggy’s home in St. Charles, Illinois, about 45 miles from Chicago. Peggy, who was driving on unfamiliar country roads, stopped at an intersection, mistakenly thinking it was a four-way stop. The truck slammed into the side of the car, causing it to spin into an electrical box.

Cynthia, who was not wearing a seat belt in the back seat, spent five days in hospital with a brain haemorrhage, a cracked rib and a bruised lung. Jim also had fractured ribs, which he learned days later – only after returning to Tampa, Florida.

Peggy was ‘a bit stunned’ but mostly unharmed when three ambulances descended on the crash site, alerted by 911. She was seen briefly in an emergency room and returned home with just a bruised sternum, grateful to have dodged a serious injury.

Then the bill came.

The patient: Peggy Dula, 55, who works at a fine jewelry store in Geneva, Illinois.

Total bill: $3,606 for ambulance services.

Service provider: Pingree Grove and Countryside Fire Protection District, a fire district serving over 50 square miles near Elgin, Illinois.

Medical services: An ambulance ride to a nearby hospital and a brief medical assessment.

Which give: All three siblings were billed for the same service: “Advanced Life Support Emergency Level 1”. This is the code for ground ambulance transportation in response to a 911 call, and it can include medical services as simple as an assessment. All three were also charged mileage charges. Jim and Cynthia were charged 15 miles; Peggy was charged 14 miles. But because they traveled in separate ambulances, each from a different nearby fire protection district, they were charged three separate amounts:

  • Cynthia was charged $1,250 — $1,100 for life support and $10 per mile — by the Burlington Community Fire Protection District.
  • Jim was charged $1,415 – $1,265 for life support and $10 per mile – by the Hampshire Fire Protection District.
  • Peggy was charged $3,606 – $3,186 for life support and $30 per mile – by Pingree Grove and Countryside Fire Protection District.

And although private, for-profit ambulance companies became notorious for their expensive bills, Peggy and her siblings were billed by taxpayer-funded fire departments.

How can fees for the exact same services vary so widely?

Cynthia Martens suffered a brain haemorrhage, a cracked rib and a bruised lung after the car accident and was rushed to hospital by ambulance. Her sister, Peggy Dula, had minor injuries but an ambulance bill almost three times that amount.(Eric Harkleroad / KHN)

“The simple answer is that these bills are all made up,” said Dr. Karan Chhabra, a surgical resident at Brigham & Women’s Hospital in Boston and a former researcher at the University of Michigan.

In a 2020 article published in the journal Health Affairs, Chhabra and colleagues looked at surprise ambulance bills by analyzing claims data from a major national insurer from 2013 to 2017. They found that 71% of Ambulance rides were off-net, meaning ambulance companies were not bound by a pre-negotiated rate with the insurer and could pretty much charge whatever they wanted. Even local fire departments can refuse to join local insurance networks.

“It’s often the municipalities that send some of the most staggering bills and often go after them very aggressively,” Chhabra said.

Pingree Grove and Countryside Fire Protection District Chief Kieran Stout said their charges are in line with the federal Emergency Medical Ground Transportation Program, which allows some public emergency services to receive additional payments for transporting patients on Medicaid, the state’s federal health insurance. program for low income people. Ambulance services fill out a cost report, and if their average cost per trip is more than the rate set by Medicaid, they receive the difference.

The Hampshire Fire Protection District uses the same program to determine the rates it charges, and the Burlington Community Fire Protection District also recently started the cost reporting process.

But ambulance services can get their full extra even if they charge non-Medicaid patients less than that average, said Jim Parker of the University of Illinois Office of Medicaid Innovation. The program is relatively new, however, and some departments mistakenly believe they have to increase their fee for each patient in order to participate, Parker said.

So, for Medicaid patients, the program will pay the difference between the ambulance company fee and the standard Medicaid payment.

But for patients with private insurance, like Peggy, the Fire Protection District bills patients directly for the balance not covered by their insurance, Stout said, a practice known as balance billing. He added that the district only bills patients who live outside the district. In the case of Peggy’s accident, the three siblings lived outside the three districts. (Jim and Cynthia eventually received car insurance settlements from Peggy.)

Congress has worked to balance billing with the No Surprises Act, which took effect Jan. 1. The law limits patient liability for most surprise bills, such as those from an out-of-network anesthesiologist who puts a patient to sleep for surgery. in a network hospital or for an air ambulance ride, almost all of which are privately owned.

But land ambulances were, controversially, exempt from the law – even though land ambulance rides are far more common. Of the 1,498,600 ambulance rides in Chhabra’s study, almost 98% were made by land ambulances.

Chhabra suspects that land ambulances received special treatment because federal lawmakers felt the need to “use caution” in their dealings with local governments. Many ambulance services are run by municipalities and may need to generate enough revenue to pay their expenses.

“Maybe that’s what they have to do to cover their own budget,” Chhabra said.

Resolution: Peggy said her insurer, BlueCross BlueShield of Illinois, estimated the “reasonable and customary rate” for services Peggy received was $1,892. He applied $400.23 to his deductible and then paid $895.06, or 60%, based on Peggy’s plan cost-sharing requirement. Pingree Grove and Countryside then billed Peggy the balance of their fees, which was $2,710.94.

Peggy disputed the balance with Paramedic Billing Services, the company that handles billing for the district, citing her siblings’ much lower charges. “Needless to say, I am speechless at the outrageously high bill I received,” Peggy wrote. “I’m willing to pay $354.94, which (along with my insurance payments) equals the amount charged to my sister for the exact same ride.”

Vice President of Paramedic Billing Services Michael Tillman said patients should dispute charges directly with the ambulance service. Peggy said her subsequent calls to Pingree Grove and Countryside went unanswered.

To demonstrate her good faith in the absence of a response, Peggy said, she sent Paramedic Billing Services $20. She received a return letter with a coupon saying she needed to set up a payment plan for the full amount, so she sent another $20. In June, she received a letter from a collection agency saying she owed $2,670.94.

“They really weren’t working with me, were they?” ” she says.

Peggy Dula is seen sitting at a kitchen table near a window.  She looks at the medical bills.
Peggy Dula’s ambulance charges were almost three times higher than those charged to her siblings for identical services.(Bram Sable-Smith / KHN)

In a statement, a spokesman for Peggy’s insurer, John Simley, said the insurer pays for ambulance services according to the terms of a member’s plan. “Some ambulance companies may charge far more than the benefits” a member’s plan provides, Simley said. “This sometimes forces members to pay for the balance of ambulance services not covered by their social security coverage.”

The takeaway: Riding in an ambulance carries financial risks. Your health may require it. But your wallet can suffer. So understand your options.

Obviously, if you are seriously injured in an accident, you have no way of knowing if the ambulance that arrives is in your network.

However, if you’re feeling fine – just a little bumped or with a laceration from a car accident or fall from a bike – remember this: you don’t have to come in just because an ambulance arrives. They arrive because they have been informed of an accident by the police or because a passerby has called 911.

Calling a friend or a car service like Uber or Lyft to drive you to a doctor, urgent care, or a hospital emergency room could save you thousands of dollars. (And please seek timely follow-up care for any possible head injury.)

It is also useful to know if your local fire department’s ambulance service is part of your insurance network, information that could influence your decision.

Of course, all of this raises the larger question of whether ambulance operations should be revenue-generating.

“Or should it just be something that’s a public good that we pay for with our taxes, like the fire department or the police,” Chhabra said, “neither of which has ever heard of anyone. who gets an invoice?”

Bill of the Month is a participatory survey conducted by KHN and NPR who dissects and explains medical bills. Do you have an interesting medical bill that you want to share with us? Tell us about it!

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