How MA SMP Program Helped Beneficiaries with Ambulance Claims

Here are some examples of how specially trained case managers at the MA SMP Program have helped Medicare and Medicaid beneficiaries resolve issues with ambulance bills. The names of the individuals profiled here have been changed to protect their privacy.

If you have a questionable bill related to ambulance or chair car service, contact the MA SMP Program at 800-892-0890 for assistance in resolving your issue.

Denial of Service Despite Medical Need

Two months after Mr. Davidson had his right knee replaced, he fell on that knee and was unable to walk. His wife drove him to the emergency room at the local hospital. There, the Emergency Room staff determined the injury would be best treated at a rehabilitation facility because he had torn a tendon but had not broken any bones.

Because he could not walk and get back into his wife’s car, the hospital arranged for an ambulance to transport Mr. Davidson to the rehab facility. The hospital did not explain to Mr. Davidson that he might have to pay for the ambulance trip.

Subsequently, Mr. Davidson was billed $1,628.08 by the ambulance company, nearly five times more than the Medicare-approved rate of $329.11. Mr. Davidson asked the MA SMP Program to intervene. An MA SMP Case Manager discovered that even though the hospital had provided a Physician Certification Statement indicating the trip was medically necessary, Medicare overruled that determination.

The MA SMP Program helped Mr. Davidson appeal the negative determination to Medicare and the original denial was overturned. Mr. Davidson was responsible for 20 percent of the Medicare-approved rate for the trip, or $65.82.

Unexpected Bill for Chair Car Service

Mr. Paulson spent several days in the hospital for treatment of his congestive heart failure. He was then sent to a rehabilitation facility for further recovery. While staying at the rehab, he returned to the hospital for a follow-up appointment. The rehab arranged for transportation to the hospital via a chair car service.

At the time the van was ordered, Mr. Paulson asked if this service was covered by Medicare and both the case manager at the rehab and the ambulance company assured him his transport would be covered since it was medically necessary. Mr. Paulson subsequently received his Medicare Summary Notice which indicated he could be responsible for up to $4,100 for this trip. He subsequently received a bill from the ambulance company for $222.23, their contractual rate with the hospital.

Mr. Paulson contacted the MA SMP Program and explained that had he known he would be responsible for paying any portion of the chair car trip, he would have arranged his own ride. A MA SMP Case Manager contacted the billing office at the rehabilitation facility. The billing clerk said it is the policy of the facility to ask the patient first if they could arrange their own transport and if not, they arrange for a chair car with a cost estimate.

The MA SMP Program Statewide Director Lucilia Prates-Ramos followed up with a letter to the facility’s manager requesting that the facility absorb the cost of the chair car service since their protocol had not been followed. The facility’s manager was in full agreement and agreed to pay the bill.

Wrong Beneficiary Billed for Ambulance Trip

Cuc Yang received a $250 bill from an ambulance company in March 2020 but didn’t know why she had been billed because she didn’t recall needing ambulance transport. She brought the bill to an MA SMP partner organization for assistance because she doesn’t speak English.

The partner organization representative sought guidance from an MA SMP Program and with the help of an MA SMP Program case counselor, they determined the bill should have gone to her younger sister, Thuc. Two months earlier Thuc had been injured in an accident at a local gym while the guest of her sister, Cuc. Thuc was transported to a local emergency room for treatment and Cuc accompanied her. Thuc was eventually admitted to the hospital for an overnight stay.

The MA SMP case counselor contacted the ambulance company and explained that there seemed to be a confusion due to a language barrier over which sister’s insurance should have been billed for the ambulance trip. The ambulance company agreed to withdraw the claim sent to Cuc’s Medicare Advantage insurance plan. They then generated a bill which was sent to MassHealth with Thuc’s insurance number.

 

Ambulance Billing Information

How Medicare Handles Ambulance Claims

To address the many complexities related to ambulance billing the MA SMP Program convened a task force. Click here to learn more about the MA SMP Ambulance Task Force.

For the latest information on what Medicare does and does not cover click here to download the MA SMP Program’s ambulance brochure.

Click here to view a video produced by the national SMP Resource Center on how to protect yourself from ambulance fraud.

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