AMED is making arrangements with Blair County that would enable the ambulance authority to prosecute patients for theft when those patients refuse to turn over insurance payments intended for AMED.

In 2023 alone, AMED has lost $243,000 in revenue because patients enrolled with Highmark didn’t forward checks sent to them by the company after the patients were transported by AMED, said AMED Executive Director Gary Watters.

AMED has obtained informal permission from Blair County District Attorney Pete Weeks for its solicitor to prosecute such cases, and AMED’s board Monday OK’d an agreement that will go to the county commissioners for approval, under which AMED will accept liability for any harm that could come to the county from those prosecutions.

Under the new policy, AMED will be going after its own money that is being withheld illegally by patients, which doesn’t mean that AMED will be prosecuting patients who simply fail to pay their ambulance bills, Watters said.

Theft by failure to make required disposition of funds is a first-degree misdemeanor, according to the proposed agreement.

The $243,000 in revenue from Highmark not turned over to AMED in 2023 was illegally withheld by a total of 87 patients, which represents the bulk of the problem, although there are other insurance companies that have also made payments not turned over to AMED, Watters said.

The Highmark losses include $9,500 and $8,000 withheld by two patients in their 20s, Watters said.

Innocent ignorance may be the reason for one or two patients not forwarding the checks, but the requirement is clear to the vast majority, Watters said.

AMED sends an initial letter informing patients they’ll be getting a check that is intended for AMED, a followup phone call 15 days later, then at least three more letters after that, if necessary — after which there are more phone calls, Watters said.

Typically, checks arrive at patients’ homes about 21 days after the service is rendered, Watters said.

Patients in their 40s and 50s are the largest cohort among the 2023 scofflaws, Watters said.

The oldest among them is 67, he said.

“It’s not like we’re dealing with elderly people who are confused,” he said.

AMED solicitor Dan Stants needed permission from Weeks to prosecute the cases because they’re based on a state statute, and county district attorneys have jurisdiction over such cases.

Stants has had a similar permission from the district attorney’s office to prosecute misdemeanor city code cases for 10 years.

The DA’s office is willing to hand off responsibility for such cases because “it has bigger fish to fry,” Stants said.

Handing off that responsibility, however, is contingent on AMED holding the county “harmless” in case of pushback, according to the agreement.

Still, such pushback in the form of a civil rights lawsuit, for example, is unlikely, because culpability for failure to turn over the payments is so clear and straightforward, according to Stants.

For policyholders who are part of a group plan, usually through an employer, the payments from Highmark go to patients, rather than directly to service providers like ambulance agencies, when those providers are “out of network,” according to Highmark spokesperson Leilyn Perri.

“In these cases, we have a direct relationship with the member (the patient), but no direct relationship with the provider,” Perri wrote in an email.

Out-of-network providers don’t have negotiated arrangements with insurance companies under which the companies pay the providers agreed amounts for specific services.

AMED doesn’t have a negotiated agreement with Highmark, because when AMED last negotiated with the company several years ago, Highmark offered payments that were less than the amounts Medicare pays — and Medicare payments were 11% lower than ambulance agency costs 10 years ago, according to an Office of Inspector General report, Watters said.

Moreover, when providers negotiate payment agreements with insurance companies, they can’t subsequently “balance bill” for the remainder of what they feel should be owed — although they can bill for deductibles and copays that the insurance companies don’t cover, Watters said.

Many ambulance agencies in Pennsylvania that are out of network with commercial insurance companies have issues with those companies sending checks to their beneficiaries, instead of to the ambulance agencies that provided the service, said Heather Sharar, executive director of the Ambulance Association of Pennsylvania.

The association has sought for the check-to-patient policy to change, Sharar said.

Some ambulance agencies would be willing to become part of commercial insurance networks, but in addition to the reimbursements for service being too low, and the prohibition against balance billing, many agencies don’t qualify, due to lack of non-emergency or wheelchair van service, Sharar said.

She objects to the balance billing prohibition.

“In what other world is it OK for someone else to tell you what you can charge?” she asked rhetorically.

In the case of Medicare, federal law requires that ambulance services accept the offered payments, Sharar said.

It’s not enough, according to Sharar.

The “reimbursement model” has not kept up with costs, which include vehicles, trained staffers, equipment and supplies — which are required at specific levels for agencies to maintain their licenses, she said.

Ambulance services don’t just provide “a ride,” Sharar said.

“It’s a mobile emergency room,” she said.