Documentation & Patient Care Reporting, EMS Insider

Patient Advocacy and Understanding Ambulance Insurance Billing

This guide can provide a bit more detail into the insurance claims process for air and ground ambulance services. Whether an incident is emergent, urgent, or non-emergent, the claim submission guidelines may vary. Once a service is provided, the ambulance provider documents the care delivered during the service, and then subsequently bills for that service.

So what does that look like?

How does an ambulance provider bill insurance?

In most cases, a request for pre-authorization of ambulance services is submitted to the insurance company. This request is then reviewed by an insurance company representative to determine the medical necessity of the transport. It’s important for an ambulance company to submit the pre-authorization request properly to ensure it gets a full and fair review. These pre-service requests generally include details about the need for a transport, where the transport will go, and why the patient requires a certain modality.

After an ambulance provider completes a service, it is important to bill an insurance company using the proper claim form. These claim forms outline patient and provider information, dates of service and diagnosis information that highlights the reason for the transport, and the billing codes associated with the ambulance provider’s fee schedule. The claim submission packet will usually include supporting medical documentation to justify the services rendered during the ambulance transport.

Reading through an insurance policy can be a challenge, even for the most seasoned ambulance provider. Understanding state prompt pay statutes, ERISA contract law, and proper coding guidelines are critical to managing the insurance claims process.

How is level of care defined?

Depending on the situation, a service generally falls into emergent and urgent transports.

An emergent case can be defined as a serious medical condition or symptom resulting from Injury, Sickness or Mental Illness, or substance use disorders which arises suddenly; and in the judgment of a reasonable person, requires immediate care and treatment, generally received within 24 hours of onset, to avoid jeopardy to life or health. A few examples of an emergent case would be rapid ground ambulance transport to the emergency room, a transport for lifesaving surgery, or even a medical flight for an organ transplant.

An urgent case can be classified as treatment of an unexpected Sickness or Injury that is not life-threatening but requires medical care that cannot be postponed. An urgent situation requires prompt medical attention to avoid complications and unnecessary suffering.

How does an ambulance provider get reimbursed?

Air ambulance transportation is a highly complex logistical endeavor involving medicine, ground transportation and potentially aviation. As such, the professional services are valuable and can be expensive. Ambulance providers aim to collect their billed charges from insurance companies and copays, coinsurance, or deductibles from patients.

What if the insurance company denies a pre-authorization or claim?

In the event that coverage is denied or only partially approved, ambulance companies have the ability to appeal the insurance company’s decision. Ambulance billing experts can assist patients and their families by submitting a memorandum of points and authorities to the insurance company. Appeals are generally supported by medical records, medical literature, and appropriate case law in an effort to overturn a coverage denial. It’s important for EMS providers to collect all the supporting documentation from the sending and receiving facilities.

To that end, it’s important to understand insurance policies to provide patient advocacy. As an EMS provider, it’s critical to collect the appropriate documentation, bill correctly, and pursue the claim to help provide the coverage each patient deserves.

What is Patient Advocacy?

Patient Advocacy is when a provider commits all of their resources to guide the process from start to finish. Patient Advocacy uses compassionate experts in the fields of medicine, logistics, insurance law, and case management to focus on every step of the process, so patients can focus on their health.

Many insurance companies provide benefits for ground and air ambulance transportation. If EMS providers are diligent, they can ensure that patients receive all of the ground and air ambulance benefits to which they are entitled.

Understanding Different Types of Insurance Plans

Whether you are billing an employee-sponsored health insurance governed by ERISA, Travel Insurance, COBRA insurance, or a plan purchased through the Health Insurance Marketplace at HealthCare.gov, it’s important to understand the plan and ambulance benefits. Each insurance product will have its own processing and applicable claims guidelines.

Air ambulance coverage is not just limited to health insurance plans, and can be identified through multiple sources. There are many circumstances where a patient might have coverage that is unknown to them. Many ambulance providers can help identify these “unknown” coverages and help secure benefits.

Here are some possibilities for additional potential coverage:

If there was a motor vehicle accident (MVA), there may be coverage for air ambulance services – even if you were somehow at fault. Patients may not know they have coverage associated with their credit card or they may qualify for particular insurance like Crime Victim’s Compensation Fund. Injuries sustained that relate to prior workers’ compensation claims may still be active and cover air ambulance transportation even if they occurred years ago.