The Ambulance Loophole That Could Cost You Big

When Jo-Anne deLeon called 911 last month because her husband Jimmy was having a heart attack, two ambulances showed up at her house. Then, a $750 bill showed up. The bill wasn’t for the ambulance, or the ride. It was for the paramedic inside ambulance No. 2, after he jumped into ambulance No. 1.

The deLeons are on Medicare, which pays for ambulance rides, but a quirk in Medicare law means that Medicare sometimes doesn’t pay for the care patients receive on the way to the hospital. There are exceptions, but essentially, Medicare pays for a simple ride to the hospital, known as BLS, or basic life services, typically provided by volunteers with limited training. When additional care is required, known as ALS or advanced life services, and a trained paramedic hops on board a BLS ambulance, Medicare won’t pay for that.

The deLeons, naturally, knew nothing about this distinction.

“We feel as if we were abused just for needing ambulance services,” Jo-Anne deLeon said. “What a farce this whole thing was.”

The situation the deLeons encountered is known as a “paramedic intercept.” It’s much more common in rural areas, such as the farm country of Duchess County, New York, where the deLeons live. To spread service coverage far and wide, many agencies take a two-tiered approach to 911 calls. Volunteers or other agencies provide basic hospital transport for emergencies, but they call for backup from trained paramedics when necessary. The ALS paramedic will often meet the ambulance en route and hop aboard — intercept it — or sometimes, meet the BLS vehicle at the location of the 911 call.

Medicare billing, which can be arcane, does not allow the agency that provides the intercepting paramedic to bill Medicare. In some situations, there’s a formal agreement in place which allows the BLS provider to bill on behalf of the ALS provider, but those are unusual, in part because they can result in lower fees. The paramedic agency can sometimes charge higher fees by billing patients directly instead, but they also face plenty of unpaid bills — and angry consumers, like the deLeons, who are fighting the bill.

In other words, no one is really happy with the awkward situation, including some members of Congress. Beginning 15 years ago, legislation has been introduced and reintroduced to plug the gap in coverage, such as the 2009 Medicare Paramedic Intercept Services Coverage Act. It, like the others, died in committee. Way back in 1994, the General Accounting Office identified the problem in a report to Congress.

Tristan North, Vice President of Government Affairs for the American Ambulance Association, said his agency hasn’t “had much success” while supporting changes to the Medicare law. James L. Robinson, president of The International Association of EMS Chiefs, said the same thing.

“This is a significant problem, and it’s got to be addressed,” said Congressman Maurice Hinchey (D-NY), back in 2011. “The last thing a senior living on a fixed income needs is to be whacked with hundreds of dollars in unexpected ambulance fees. The current policy unfairly discriminates against Medicare beneficiaries. We simply cannot have seniors second guessing whether to call an ambulance for fear of the bill. These are important health care services and they should be covered. Hopefully, CMS (which administers Medicare) will change its policy.”

That seems unlikely. In a statement to Credit.com, the Centers for Medicare and Medicaid spelled out the policy.

“The Medicare benefit for ambulance services is limited by the statute (the Social Security Law Act) to a transportation benefit; that is, payment may only be made to the entity that actually transports the patient,” the agency said. “Except in very narrow circumstances spelled out by statute, the paramedics would be paid under a contract with the transporting entity; they cannot directly bill and be paid by Medicare.”

The tricky ALS/BLS distinction can cost anyone — not just Medicare patients. Private insurance often pays for both transportation and paramedic care, but policies vary widely. There can be separate deductibles, for example, or other surprises. As with all things medical, it’s important to appoint someone other than the patient to ask questions, both when care is given, and later, when the bills arrive.

Medical debts that go unpaid can cause serious problems for your credit. If you’ve been trying to sort through medical bill issues, it’s a good idea to check your credit reports to see if any have been sent to a debt collector. Collections accounts can lower your credit scores considerably, and can cause problems for you when you need to obtain credit down the road. You can check your credit reports for free once a year through AnnualCreditReport.com, and dispute any errors or issues with the creditor as soon as possible. You can also monitor your credit scores through free services like Credit.com to watch for changes in your score that could indicate a problem that needs your attention.