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Pa. Bill Could Change Insurance Reimbursement for EMS

Pittsburgh—Emergency medical service agencies are awaiting state Senate consideration of a bill that would change the way insurance companies reimburse them.

When the agencies do not have contracts with insurers, the companies send reimbursement checks to patients, who are supposed to forward the money to the EMS agencies but often pocket them, officials say.

"If you were an honest person, you would forward me that check," said J.R. Henry, president of Valley Ambulance Association in Moon. He estimates Valley lost more than $250,000 over the past five years because of indirect payments. "At the doctor's office, you pay your co-pay before you see the doctor.

"How in the world am I supposed to collect when you're laying in the street after getting hit by a car?"

The House on Nov. 1 unanimously approved a bill that would require companies to directly pay EMS agencies that are unaffiliated with insurers when they provide services. It is unknown when the bill will come up for Senate consideration.

Insurance companies do not support the legislation. They want EMS agencies to contract with them, saying that allows them to oversee quality of services and set rates.

"Mandating direct payment eliminates any incentive for an ambulance provider to join our networks. The vast majority of health care providers voluntarily elect to join Highmark networks and agree to follow certain quality, fraud and billing requirements," said Michael Weinstein, a spokesman for Highmark, the largest insurance provider in the state.

Not getting direct reimbursement is one reason ambulance services are struggling to stay afloat, said Heather Sharar, executive director of the Ambulance Association of Pennsylvania in Perry County.

EMS leaders say the poor economy has led to fewer subscribers and contributions from municipalities. At the same, increasing insurance rates have pushed up co-payments and out-of-pocket plan deductibles.

But the biggest problem, EMS officials said, is that Medicare and private insurance payments cover only about 50 percent of the cost of ambulance trips and the service that paramedics and EMTs provide.

"Anybody in health care today knows it's tough," said Mike Markilinksi, general manager for Guardian Angel Ambulance of West Mifflin. "The payments range anywhere from 100 percent to as low as 17 percent."

In June, Pittsburgh City Controller Michael Lamb released a report saying that just six of the 17 emergency service agencies operating in the 36 municipalities that are part of the Congress of Neighboring Communities, an organization based at the University of Pittsburgh, were self-sufficient.

State records show that 48 ambulance services operate in Allegheny County, about half the number of 15 years ago. Among those closing in Western Pennsylvania in the past 10 years are Arnold Volunteer Ambulance Service in Westmoreland County, Prism Health Services in West Mifflin and Mercy Mobile Care, operated by Pittsburgh Mercy Health System.

Bryan Kircher, president of Ross/West View EMS association, said he fears that if revenue continues to slide, more agencies could close their doors.

"When it's costing me more money to send a truck out the door than the money we get to provide that service, it doesn't take long to figure out that you can't continue to do that," he said.

Rick Adobato, operations manager for Fayette EMS, said the change has been needed for many years. He said he could not estimate how many thousands of dollars receiving direct payments would generate for Fayette EMS.

"It would be huge for us. The fact is, for years, the insurance companies have blocked this and in the end, we don't ever see the money," Adobato said.

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