The Case of the $489,000 Air Ambulance Ride

Sean Deines and his spouse, Rebekah, had been road-tripping after he misplaced his job as a bartender when the pandemic hit. But whereas visiting his grandfather in a distant half of Wyoming, Sean began to really feel very in poor health.

Rebekah insisted he go to an pressing care heart in Laramie.

“‘Your white blood rely is thru the roof. You have to get to an ER proper now,’” Deines, 32, remembers a staffer saying. The North Carolina couple initially drove to a hospital in Casper however had been shortly airlifted to the University of Colorado Hospital close to Denver, the place he was admitted on Nov. 28, 2020.

There, specialists confirmed his analysis: acute lymphoblastic leukemia, a fast-growing blood most cancers.

“Literally inside 12 hours, I wanted to determine what to do with the subsequent step of my life,” mentioned Deines.

So, after he was began on intravenous remedies, together with steroids and antibiotics, in Colorado to stabilize him, the couple determined it was prudent to return to North Carolina, the place they might get assist from his mom and mother-in-law. They chosen Duke University Medical Center in Durham, which was in his insurance coverage community.

His household known as Angel MedFlight, half of Aviation West Charters of Scottsdale, Arizona, which informed Rebekah Deines that it might settle for no matter the couple’s insurer would pay and that they’d not be held chargeable for any remaining steadiness.

Sean Deines was flown to North Carolina on Dec. 1, 2020, and brought by floor ambulance to Duke, the place he spent the subsequent 28 days as an inpatient.

By his discharge, he felt higher and issues had been wanting up.

Then the payments got here.

The Patient: Sean Deines, 32, who bought protection by the Affordable Care Act market with Blue Cross Blue Shield of North Carolina.

Medical Service: A 1,468-mile air ambulance flight from Colorado to North Carolina, together with floor transportation between the hospitals and airports.

Service Provider: Aviation West Charters, doing enterprise as Angel MedFlight, a medical transport firm.

Total Bill: $489,000, most of which was for the flight from Denver, with roughly $70,000 for the floor ambulance service to and from the Denver and Raleigh-Durham airports.

What Gives: Insurers usually get to determine what care is “medically essential” and due to this fact coated. And that’s typically in the eye of the beholder. In this case, the debate revolved first round whether or not Deines was secure sufficient to securely take a three-plus-hour business flight to North Carolina throughout a pandemic or required the intensive care the air ambulance offered. Second, there was the query of whether or not Deines ought to have stayed in Denver for his 28-day therapy to get him into remission. Insurers have a tendency to not contemplate affected person stress or household comfort of their selections.

Also, each air and floor ambulance companies have been heart stage in the nationwide struggle over large shock payments, since the for-profit corporations that run them often don’t take part in insurance coverage networks.

Angel MedFlight, which was not in Deines’ insurance coverage community, sought prior authorization from Blue Cross Blue Shield of North Carolina. The request was dated Nov. 30, however the insurer mentioned the fax arrived in the predawn hours the similar day as the flight, Dec. 1, 2020.

On that day, Angel MedFlight flew Deines to North Carolina in an airplane, together with a nurse to supervise his IV drugs and oxygen ranges.

Angel MedFlight spokesperson Kimberly Halloran didn’t reply a selected written query from KHN about why the flight went forward with out prior approval; typically medical interventions are postponed till it has been obtained. But in an emailed assertion, she mentioned the firm “happy every step in the medical health insurance course of and transported Sean to his long-term well being care suppliers in good religion.”

According to the overview of the case achieved months later by an impartial evaluator, Blue Cross on Dec. 3 denied protection for the air ambulance companies as a result of medical data didn’t help that it was an emergency and Deines was already in an applicable medical facility.

At the finish of December, an attraction was filed towards that call on behalf of Deines by Angel MedFlight.

Then, in March 2021, Blue Cross despatched Deines a verify for $72,000 to cowl half of the $489,000 invoice, which he forwarded to the air ambulance firm. The clarification of advantages confirmed the majority of the costs had been dominated “not medically essential.”

Sean and Rebekah Deines look over medical payments at house in Hendersonville, North Carolina.(Maddy Alewine for KHN)

Angel MedFlight, by a income administration agency it hires known as MedHealth Partners, continued to attraction to Blue Cross to overturn the denial of the flight portion of the invoice.

Then, three months after Blue Cross despatched the verify that Deines then despatched on to Angel MedFlight, the insurer demanded Deines pay again the $72,000.

“The preliminary thought was ‘I can’t consider that is taking place,’” mentioned Deines.

Medical necessity standards are set by insurers, with North Carolina Blue Cross masking air ambulances in “distinctive circumstances,” corresponding to when wanted therapy isn’t accessible domestically.

When Deines, who was nonetheless unemployed and present process therapy, couldn’t pay, the debt was despatched to collections.

In late June, Deines’ representatives at Angel MedFlight took the subsequent step allowed below the Affordable Care Act, interesting the insurer’s inner willpower that the flight wasn’t medically essential to an impartial third get together by the state.

On July 29, the evaluator dominated in favor of Blue Cross.

Normally, such a flight can be applicable as a result of the affected person was “medically unfit to journey through business airflight,” the overview famous. But, it went on to say, there was truly no have to journey, as the University of Colorado Hospital — a member of the National Comprehensive Cancer Network — may have managed Deines’ therapy.

His well being plan “clearly stipulates their indications for medical flight protection and, sadly, this case doesn’t meet that standards,” the overview concluded.

Resolution: The invoice disappeared solely after the press bought concerned. Shortly after a KHN reporter contacted the communications representatives for each the insurer and Angel MedFlight, Deines heard from each of them.

The $72,000 cost was made in error, mentioned Blue Cross spokesperson Jami Sowers.

“We apologize for placing the member in the center of this difficult scenario,” she mentioned in an e mail that additionally famous “the air ambulance firm billed greater than $70,000 only for floor transportation to and from the airport — greater than 30 instances the common price of medical floor transport.”

Such a scenario would “usually” be flagged by inner techniques however for some cause was not, Sowers mentioned.

“I’ve by no means heard of a floor transport that prices that a lot. That’s surprising,” mentioned Erin Fuse Brown, director of the Center for Law, Health & Society at Georgia State University College of Law, who research affected person billing and air ambulance prices.

Still, there’s excellent news for Deines: Both the insurer and the air ambulance firm informed KHN he won’t be held chargeable for any of the costs. (None of the costs stemmed from his first air ambulance flight from Casper to Denver, which was coated by the insurer.)

Sean and Rebekah Deines pet their canine, Maddi, at house in Hendersonville, North Carolina.(Maddy Alewine for KHN)

“Once North Carolina Blue engages in our formal inquiries about its refund request, the standing of the funds will probably be resolved,” the ambulance spokesperson wrote in her e mail. “One factor is definite, Sean won’t need to pay for North Carolina’s wavering protection choice.”

In an e mail, Sowers mentioned Blue Cross had “ceased all recoupment efforts” associated to Sean’s case.

The Takeaway: If the flight had occurred this yr, the couple might need acquired extra worth info earlier than they took the flight.

A legislation known as the No Surprises Act took impact Jan. 1. Its important thrust is to guard insured sufferers from “steadiness payments” for the distinction between what their insurance coverage pays and what an out-of-network supplier costs in emergencies.

It additionally covers nonemergency conditions through which an insured affected person is handled in an in-network facility by an out-of-network supplier. In these instances, the affected person would pay solely what they’d owe had the service been absolutely in-network.

Another half of the legislation, known as an excellent religion estimate, might need offered Deines with extra transparency into the prices.

That portion says medical suppliers, together with air ambulances, should give upfront price estimates in nonemergency conditions to sufferers. Had the legislation been in impact, Deines might need realized earlier than the flight that it could possibly be billed at $489,000.

Insured sufferers in related conditions as we speak ought to all the time verify first with their insurer, if they’re in a position, to see if an air transport can be coated, specialists mentioned.

Even if the legislation had been in impact, it doubtless wouldn’t have helped with the massive hang-up in Deines’ case: the disagreement over “medical necessity.” Insurers nonetheless have leeway to outline it.

For his half, Deines mentioned he’s glad he took the flight to be nearer to house and household, regardless of the later monetary shock.

“I’d not change it, as a result of it offered help for myself and my spouse, who wanted to take care of me; she was protecting my sanity,” he mentioned.

Stephanie O’Neill contributed the audio portrait with this story.

Bill of the Month is a crowdsourced investigation by KHN and NPR that dissects and explains medical payments. Do you’ve an fascinating medical invoice you wish to share with us? Tell us about it!

Julie Appleby:
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