AMED losing out on payments

Ambulance company deprived of at least $160,000 last year

During a review of financial documents at a board meeting this week, AMED Executive Director Gary Watters reiterated his dissatisfaction with a 2015 state law whose initial impetus was to help ambulance services being stiffed by patients who refused to forward direct payments they received from their insurance companies for transports.

Although only about 3 percent of AMED’s patients receive direct payments from insurance companies and only 20 percent of those refuse to forward the payments to AMED, such failures nevertheless deprived AMED of at least $160,000 in revenue last year, Watters said.

An initial bill that dealt with the problem was straightforward, calling for “a claim covered under a health insurance policy for a service performed by the emergency medical services agency (to) be paid directly to the emergency medical services agency.”

The eventual law, however, requires ambulance services to opt in annually, then accept in-network payments from the insurance companies — minus any deductibles, co-insurance or copays, which they would need to bill the patients for, according to Watters and a brief on the law published by the Pennsylvania Emergency Health Services Council.

The in-network amounts are normally about what Medicare pays, maybe a little more, ranging “typically anywhere from $400 to $600 less what an average EMS agency would routinely charge for services rendered,” according to the brief.

The amounts actually tend to be less than what Medicare pays, according to Watters.

Moreover, ambulance services that opt in don’t know what the in-network payments are beforehand, Watters said.

Additionally, ambulance services that opt-in may not “balance bill” patients for the rest of their charges, according to the brief.

The payments available through opting in are so poor that very few ambulance services participate, Watters said.

Asked why some insurance companies continue to make payments directly to patients, Watters said, “It’s a tactic” — designed to nudge the ambulance services to accept the in-network payments.

A large western Pennsylvania insurance company opposed the initial straightforward version of the law because it undermined the concept of networks, which are based on negotiating discounts with providers, a spokesman for that insurance company told the Mirror in 2015.

The law ended up favoring insurance companies because of their successful lobbying, Watters said.

Lawmakers tried “to appease both sides,” he said.

AMED is hopeful, however, of a remedy, Watters indicated.

He declined to give specifics, although a question from a board member indicated that it might relate to an effort to deal with “fraud.”

Mirror Staff Writer William Kibler is at 949-7038.