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Does Your Health Insurance Cover Ambulance Transport?

Do you think your health insurance covers ambulance transport? Better read the fine print of your policy to be sure.

Recently I represented a client by filing an appeal with her insurance company for coverage that had been denied. This was a first for me, but fortunately the outcome was educational and financially rewarding for my client. The denied claims were for non-emergency ambulance service from the nursing home where she resides back and forth to medical appointments.

As a Medicare recipient with a premium supplemental policy from a prominent insurance company, my client was astounded to receive a letter denying coverage because her ambulance rides were not provided by the “preferred provider” stipulated in her policy. Suffering from both dementia and physical conditions which require her to be heavily medicated, it might seem obvious that my client is in no way competent to monitor her nursing home’s selection of an ambulance company. Evidently the insurance company didn’t see it that way!

Investigation of the provider selection process which resulted in coverage denial brought me to the nursing home, the preferred provider ambulance company, and the unapproved ambulance companies who ultimately provided her rides. In summary, my findings were as follows:

In an emergency, private insurance companies will cover the cost of ambulance transport provided by any ambulance company.

• Non-emergency calls must be pre-approved, with proper documentation to substantiate the “need” for an ambulance.

• Insurance companies generally shop around for the best deal and negotiate a below market rate with one ambulance provider to whom they issue a preferred status contract.

• It is the responsibility of the insured party to know which ambulance company is “preferred,” and contact them exclusively for non-emergency transportation.

• The preferred provider in turn subcontracts with other providers to deliver service, in the event that the preferred provider is unavailable at a requested time.

• If the preferred provider is not contacted initially, then the insurance companies can deny coverage of the transportation provided by a third party, leaving the policy holder responsible for payment in full.

From the nursing home, I discovered that ambulance transport may be requested by various individuals on staff at the facility, and that attention to one’s insurance coverage may or may not be considered in the selection of a provider. In fact, those placing the calls often prioritize a provider based on how little red tape is involved when making a request. An ambulance dispatcher who asks the fewest number of prequalification questions, including those about insurance coverage, saves time for the staff member who frequently is being pulled in several different directions while trying to place the call.

When asked, both ambulance providers and nursing home staff admitted to me that a patient’s insurance information often is not confirmed until the time of pickup. In fact, one ambulance driver told me it is common practice to pick up patients whose insurance companies do not contract with their company for non-emergency transport. Their rationale is that if service is provided, and coverage is denied, the uncovered costs will trickle down through the system landing with the nursing facility or ultimately with the insured party, and the chance of at least partial recovery is very good. The consumer who receives an EOB (explanation of benefits) letter specifying non-coverage is likely to assume responsibility and pay the bill because he or she does not want to risk jeopardizing his or her credit history while disputing the charges.

Appeals are time consuming, but if you are willing to gather the facts and compile the documentation to plead your case, the results can be rewarding. It is your responsibility to understand your policy, but if someone else (e.g. a nursing home) is acting on your behalf, they have an obligation to follow the rules of your policy. Furthermore, ambulance companies know with which insurance companies they contract, and they are obligated to inform you if your policy will not cover their services. Hiring someone experienced in navigating the medical care maze may be an efficient alternative to doing it yourself. In this case, the result was a savings of more than $16,000 for my client, and a lesson well learned about knowing the parameters of one’s policy.