Medicare denials stoke questions about ambulance company's billing

April 30--His wife of 55 years couldn't move from the blue Lazy Boy chair that served as her bed. She could barely speak.

Otis Hinkle, a retired Navy captain, called 911 and asked for an ambulance to rush to his Oxnard home.

A month later, after his wife Lynn died of cancer that had started in her bladder and moved to her liver, Hinkle learned Medicare payment for the ambulance had been denied. He owed about $1,850.

J. Robert Bradish, 79, also of Oxnard, called for an ambulance to transport his wife who, as it turned out, needed immediate gall bladder surgery. They received a notice of Medicare's denial and a bill for $1,126.25.

Katharine Raley, Ventura County's insurance advocate for seniors, has reported

14 cases in which people covered by Medicare were denied payment for ambulances. In one case, which was later resolved, a man died two hours after arriving at the hospital, but his wife was told she owed more than $1,000, Raley said.

In several situations, seniors were told that if they didn't pay, their bills would be sent to a collection agency.

All the cases involve transports by American Medical Response, the nation's largest private ambulance provider and owner of two transportation services in Ventura County. Raley said at least one of the initial denials -- the Bradish case -- was reversed by Medicare's administrative contractor.

Reports of the local cases were sent to the government-funded Senior Medicare Patrol watchdog group, which has received more than 50 cases statewide of Medicare-denied ambulance payments in transports involving AMR.

Issues include Medicare's guidelines for covering ambulance transportation and concerns by advocates about how AMR reports details of a transport to Medicare.

Jason Sorrick, a spokesman for AMR, said the company knows of the concerns and is working on the issues with senior-insurance advocates across the state. He said the denials happen because of Medicare's guidelines on which transport situations are medically necessary.

A regional spokesman for the U.S. Centers for Medicare & Medicaid Services said he couldn't comment. Medicare guidelines say ambulance expenses will be covered when other transportation would jeopardize a patient's health.

"Just because it's in the 911 system doesn't mean it's going to be approved by Medicare for reimbursement," Sorrick said.

CODING factor

Senior advocates say the problem may rest with the way AMR crews code ambulance transportation. Raley, program manager of the Ventura County Health Insurance Counseling and Advocacy Program, said AMR has declined to provide copies of her clients' ambulance trip reports. But she said patient medical records and information from an involved insurance company show some local cases involve imminent health threats that meet Medicare guidelines but may not have been conveyed in ambulance reports submitted to the government.

She said the ambulance report on the patient who died soon after arriving at a hospital may have included too little information on the medical condition. Raley said she has asked ambulance officials several times to resubmit bills to Medicare with more information but that they have refused.

Sorrick said patient privacy laws bar him from discussing specific cases. He said trip reports can be obtained when patients or family members sign releases and provide necessary documents.

Sorrick said AMR follows Medicare guidelines for coding, providing information that includes a patient's vital signs, primary and secondary symptoms, and care administered by the ambulance crew.

"It's a very stringent process," he said, suggesting the problems emerge when conditions seem dire but still fall short of Medicare guidelines. "There are going to be circumstances where it falls in a gray area."

The company transports about 700,000 people a year in California, including about 46,000 people last year in Ventura County. Sorrick said more than half of the trips go unpaid, often because people are uninsured.

In cases involving people covered by Medicare, Raley worries. When she asks groups of seniors if they've had ambulance trips denied, hands go up.

"Many clients have paid 100 percent out of their pocket," she said, adding that many seniors don't know how to appeal a case or just assume they should pay it.

She worries more seniors may decide they can't afford an ambulance.

"We don't want them not to call when it's life or death," she said.

statewide issue

According to a publication provided by Medicare, ambulances are generally covered when people need treatment during a transport. Ambulances also are usually covered when people are in severe pain, bleeding, in shock or unconscious.

When Medicare pays for an ambulance, it covers 80 percent. The balance is often covered by supplemental insurance. Sorrick said that if payments are denied for a low-income senior who meets AMR's guidelines for compassionate care, the debt may be discounted or forgiven.

A Medicare spokesman declined to comment on questions about AMR or ambulance coverage. He suggested people with problems contact Medicare or a health insurance counseling and advocacy group.

Micki Nozaki, a case specialist with Senior Medicare Patrol, said that over a year she collected more than 51 complaints about Medicare denials involving AMR across the state. She said her group wants Medicare to audit AMR's coding procedures.

"If we're getting that many concerns across the state of California, all with the common theme, it's natural to assume it's the tip of the iceberg and there's more cases we haven't heard about," she said.

A year ago, AMR officials met with insurance counseling and advocacy program leaders from across the state to discuss situations in which Medicare denies claims. Afterward, someone at the ambulance company was designated to deal with the program's complaints. The company also established a 90-day waiting period when the billing process would be delayed if an appeal was planned. But Raley said the 90-day waiting period isn't always followed.

Nozaki said AMR is trying but that she still gets complaints about transports for which Medicare denied payment.

Sorrick said the company wants to resolve problems.

"We're in the business of patient care and saving lives," he said. "The last thing we want is for people to have stress related to the services we're providing."

PERSONAL BATTLE

In the final stages of her battle with cancer, Lynn Hinkle started sleeping in her Lazy Boy. Her husband watched over her by sleeping in a matching chair next to hers.

Hinkle said she was almost comatose on the day he called 911. He couldn't move her. The emergency medical technicians had to lift her out of the Lazy Boy. At the hospital, she was given two units of blood and, because of severe dehydration, saline.

Hinkle said a doctor told them the cancer had advanced and that she needed hospice care. She returned home and died about two weeks later, on Aug. 25.

He said the Medicare claim was denied three times. He received repeated bills from Gold Coast Ambulance Service, which is owned by AMR. The last one threatened to place him in collections.

Hinkle tried repeatedly to obtain the reports showing the billing used. He said he was told the paperwork he sent hadn't been received.

He never saw the report. But he said an ambulance company employee told Raley that his wife's condition had been reported as fatigued.

His fight to get his claim reversed could be ending. Raley told him last week that Medicare had agreed to review his case.

"It wasn't the $1,800; it was the principle of the thing," Hinkle said, trying to explain how collecting her medical records and badgering Medicare and AMR meant the image of the ambulance trip rolled through his mind like it was on a video loop.

"It was not only losing her; it was having to relive it almost every day," he said.

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