Last summer, a man in his early 30s had a seizure in his apartment in Boston and was rushed to the hospital by ambulance after his girlfriend called 911.
The man, who asked to be identified only by his first name, David, recovered. But he was shocked by the bill he later received from Boston Emergency Medical Services, the ambulance service run by the City of Boston.
Boston EMS billed David about $1,050 for the 3-mile trek from the Fenway to Massachusetts General Hospital, in addition to the $400 David’s health insurer had already paid.
David questions why consumers sometimes get stuck with large bills, even when they have top-flight insurance.
I learned that how much you get billed — or if you get billed at all — depends largely on whether the ambulance service you use is “in network,” that is, whether it is under contract with your health insurer. And that’s a situation, particularly in an emergency, over which you have little control.
Staying in network is the obvious thing to do when it comes to elective surgery and other kinds of planned medical treatment. If the provider is in your network, your cost, or much of it, will be covered.
If you opt to go out of network it will cost you more.
But a seizure isn’t planned. People call 911 in a panic and are grateful when the ambulance arrives. But whether that ambulance is in your insurance network is pretty much out of your control.
The city or town in which you live dictates which ambulance service covers you and your neighbors. And that service may or may not be in your network. You probably don’t know. I didn’t know when a family member was rushed to the hospital from my home a couple of years ago. But I was lucky. The entire cost was covered by my insurer, Blue Cross Blue Shield.
Some municipalities, such as Boston, run their own ambulance service. But others, including my city, contract with a private company. And, in my case, that company just happened to be in network with my insurer. We never got a bill. (Our deductible had been met by the time we needed the ambulance.)
But people who are taken to a hospital by ambulance in Boston almost certainly will be billed if they have private insurance. That’s because Boston EMS is not in network with any private insurer. You are covered in Boston only if you are on Medicare or Medicaid, which are public insurers. Otherwise, expect to get a bill.
It’s a practice known as “balance billing,” one that Congress has attempted to prohibit.
In David’s case, his insurer, Blue Cross Blue Shield, paid about $400 on his behalf, an amount based on the Medicare rate multiplied by a certain factor. David paid about $50 in coinsurance. The total bill was about $1,500.
David said he has a good job and can absorb the cost of an unexpected bill, if he must. But he worries about people less financially secure than he is. Would someone knowing the out-of-pocket cost of an ambulance ride decide not to call 911 in an emergency for that reason?
Actually, if you have been balance billed for ambulance service you should think twice before paying it. That’s because, if you push back, or simply don’t pay the bill, either your insurer or your ambulance service provider may cover it. That’s the practice in the industry.
In those circumstances, insurers and providers are engaged in a sort of tug of war over who should pay.
Boston EMS told me it encourages people like David who have been balance billed to resubmit their claim to their insurer “which often results in the bill being reprocessed at the full amount.”
If that doesn’t work, Boston EMS said, it has a “robust compassionate billing practice, including hardship waivers.” It has never sent an unpaid bill to a collection agency, it said.
That struck me as a good thing for those who have the gumption (and time and skill) to challenge their bills. But what about those who, for whatever reason, actually pay the bill? It doesn’t seem fair to them or to those who don’t pay and worry what might happen.
Boston EMS was unable to tell me how much money it receives from people who pay their bill without questioning it. In David’s case, at about the time I began making inquiries, his $1,050 bill was put on hold by Boston EMS.
BCBS, for its part, said it sometimes chooses to take “a compassionate approach” in covering the cost when members get balance billed for ambulance services, although it is “more often the provider who writes off the balance.”
Another thing I found out is that some insurance plans provide better ambulance coverage for HMO members than for higher-tier PPO members. I know it’s a bit counterintuitive. Check your policy.
So, if you are concerned about your level of coverage, find out from your city or town what ambulance service covers you. Last year, when I was working on a different story about health insurance, BCBS provided me with a list of its in-network municipal providers, which included Weston, Ashland, Westford, Methuen, and Raynham.
The BCBS list of in-network private providers included Brewster, Cataldo, Armstrong, Fallon, and American.
Once you know your provider, check with your insurer to see if it’s in your network.
Of course, if you are injured in a car accident or other mishap away from home, the ambulance that takes you to the hospital may not be in your network and you may get billed.
Last year, Congress prohibited balance billing, effective Jan. 1, with one big exception: ambulance services.