Opinion: Know your options in emergency service billing

Myleah Shrimpton

Although I prefer to have solid solutions before bringing an issue to the table, I have come to realize my position is just as much about educating as it is advocating. In my role, I have been a witness to the unfortunate trend of balance billing that has escalated throughout the years, particularly in the area of air and ground ambulatory services.

With nearly one-quarter of Americans underinsured due to coverage gaps or high out-of-pocket costs, according to the Commonwealth Fund, ambulatory services are one of the largest concerns from my perspective because they are not easily overturned in an appeal and there are no current protections at state and federal levels. When an emergency arises and this type of care is required, the patient typically has no authority to direct their own care and they are at the mercy of the closest provider to respond. If the ambulatory service is not a contracted provider and are outside of the network under fully insured plans, the carrier must pay the in-network contracted allowed rate. However, the patient can still be responsible for the amount in excess of the in-network contracted allowed rate, also known as the balance bill, which can account for thousands, or tens of thousands, of dollars.

On Dec. 27, 2020, the federal No Surprises Act was signed into law as part of the Consolidated Appropriations Act of 2021. Going into effect on Jan. 1, 2022, it establishes that patients using air ambulance services, a helicopter or airplane, would be afforded similar consumer protections against surprise medical billing for emergency services. Patients would be required to pay only the in-network cost-sharing amount for out-of-network air ambulances and could count the cost-sharing toward their deductibles. Beginning Jan. 1, 2022, out-of-network air ambulance providers would be barred from sending patients balance bills for more than the in-network cost-sharing amount.

However, the federal legislation only addresses air ambulatory services and not ground. In Missouri, protections against balance billing only apply if the provider and insurer voluntarily agree to participate in the process, according to the Commonwealth Fund. There are potential preventive solutions, such as subscription services, that will reimburse the cost of emergency ambulatory services to help fill in coverage gaps. However, I personally recommend the contract terms and conditions are reviewed carefully and a plan is selected that has a provider-neutral reimbursement structure. 

Here are a few recommendations on what you can do if you find yourself the victim of a balance bill for this type of emergency service:

• Be your own advocate. Review your explanation of benefits for total billed charge amounts and ask questions if you are unsure. You might even consider running the current procedural terminology, better known as CPT codes, on the American Medical Association’s website to make sure the billing itemization is accurate.
• Know your rights. Once you have scrutinized your bill and have determined the charges to be accurate, carefully review your appeal rights outlined on your EOB subject to your carrier. There are deadlines and processes associated with each carrier. If questions arise, contact the carrier directly, consult with your human resources department or reach out to the claims department of your broker. If the appeal outcome upholds the original decision, you have the right to file a complaint with the Missouri Department of Insurance, which can conduct an independent review and render a decision.
• Negotiate. If the carrier and provider are unwilling to come to a viable agreement, appeals have failed, and the Department of Insurance does not overturn the initial carrier appeal – it is time to review other negotiating options.
• Ask for a write-off. Work with the provider/billing entity directly to see if they would be willing to write off the excess balance bill amount. If they will not write off the amount in its entirety, see if they would agree to a compromised settlement amount. If you are uncomfortable with this process, enlist the help of your trusted broker.
• Payment plan. If there is no compromise, see if the billing entity would work out a payment plan for the charges you cannot pay outright.

While strides are being made at the state and federal levels, this continues to be a topic of complexities and nuance. Be informed, stay curious and make sure you have a team of trusted advisers.

Myleah Shrimpton is the director of claims for Ollis/Akers/Arney. She can be reached at myleah.shrimpton@ollisaa.com.