Opinion: Addressing Balance Billing in Ground, Air Emergency Transportation

April 23, 2020

Health Affairs' study points out problems with balance billing, but doesn’t address entire issue.

A recent study titled, “Most Patients Undergoing Ground And Air Ambulance Transportation Receive Sizable Out-Of-Network Bills,” was published by Health Affairs and examines balance billing from one point of view. But, it's important to provide thoughts from the perspective of an emergency air ambulance provider that has first-hand experience with the issue. 

During the past several years, and before any legislation was considered, Air Methods has certainly recognized the problem of balance billing in its industry and has enacted a variety of strategies to take patients out of the middle of this complicated process. A key initiative of Air Methods has been to partner with insurance companies all over the country to reach in-network agreements. This has proven to be the most effective way to ensure patients do not have to deal with unexpected charges.

The average out-of-pocket cost for our patients amounts to just a little over $200 while the study refers members of a large national insurance plan from 2013–17 are receiving bills of $450 for ground transportation and $21,698 for air transportation. Our prevailing tendency, through our Patient Advocacy process, to forgive the balance left by the insurance company contradicts much of the premise in this study.

The study states that, “legislation at the state and federal levels is being considered to protect patients from these ‘surprise bills,’ defined as out-of-network charges.” While these legislative efforts are underway, Air Methods has proactively and independently worked with insurance companies and has reached agreements with 54 health plans to date.

Our goal is to be 100% in-network nationwide. In-network coverage offers health plan members a discounted, out-of-pocket payment for qualified services, which varies depending on their plan’s benefits. It is important to note that health insurance companies control who is “in-network” for their plans, and, unfortunately, some of the largest national payers, United Healthcare, Cigna and Aetna, have been unwilling to add Air Methods as an in-network provider at rates consistent with what they are already paying today.

Another key detail in the Health Affairs study is its frame of reference, which does not take into account work that has been done over the past three years (all data is from 2013 to 2017). The gap in data from 2017 to present is particularly significant to Air Methods, as we have made a great deal of progress in eliminating balance bills during the past three years - going from just 6% in-network to nearly 50% today. This means more than 80% of the population is covered for Air Methods’ services either through commercial insurance or through Medicare or Medicaid, so they will not receive a balance bill for services. Once these final three large national payers mentioned above allow us to be in-network, we will, for all intents and purposes, be very close to our 100% goal and have the ability to eliminate balance bills.

Along with our own efforts to partner with insurance companies, we continue to work with state and federal legislatures for a more accurate Medicaid and Medicare reimbursement model. Currently, more than 70% of air medical flights are Medicare, Medicaid or self-pay/uninsured, which only covers approximately 30% of the median cost of a flight. At the federal level, we support legislation that would preserve access to these life-saving services, while addressing the issue of consumer costs by updating the Medicare reimbursement rates of air medical services to be based on the actual cost of care, which has not been updated in over 20 years.

What should also be known is the denial rate of health insurance companies when it comes to emergency air medical transports. On average, more than 50% of our emergency air medical transport claims are denied by insurance companies on first examination. That means the patient and the provider must appeal to the insurance company for payment using the process created by the insurance company itself. And it often takes months of appeals before the patient knows whether their insurance company will cover the cost of the emergency air medical transport. Almost every single denial is overturned after this lengthy and time-consuming appeal process.

At Air Methods, we only balance-bill for two very specific reasons: first, if the patient does not provide us with their insurance coverage information so we can bill their insurance company or if they do not assist in the appeals process - which is a requirement set by the insurance company; second, if the insurance company sends the payment for emergency services directly to the patient, who then either willfully or as directed by insurance, does not send the reimbursement check to Air Methods (the provider) for payment of medical care.

It's also mentioned in the study that researchers were not able to observe whether patients were balance-billed. However, the potential for a balance bill does not equate to an actual balance bill. A health insurance company’s reimbursement behavior dictates that potential. The study lays the blame for a potential balance bill not at the feet of the insurance company for its lack of reimbursement, but solely with the provider.

Our healthcare system is complicated and, unfortunately, patients are indeed often caught in the middle. While the issue of balance billing and the cost of air medical transportation is complex, Air Methods continues to actively work with all willing parties to make sure patients can focus on recovery and that insurance fairly covers this necessary service.

JaeLynn Williams is CEO, Air Methods.