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Why Medicare might deny ambulance costs

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The following refers to Original Medicare. An individual with an Advantage Plan would likely find that the rules for ambulance transportation vary by plan while the costs, rights, protections and choices may be different. Those individuals with an Advantage Plan should read the plan material or call their plan for clarification.

Medicare Part B (Medical Insurance) covers emergency and non-emergency ambulance transportation but it’s important to understand the exceptions and the costs AND have a good handle on some of the vocabulary involved with ambulance transportation since failing to understand could result in a denial of coverage. While the denial can always be overturned, the current backlog of Medicare hearings means that getting the denial overturned could potentially take years.

In a world of copays and deductibles, you know that you’ll be chipping in on the cost as well. So how much would you have to pay? If Medicare agrees that it will cover the trip, your portion will be 20 percent of the Medicare-approved amount after you’ve met the yearly Part B deductible. All ambulance companies must accept the Medicare-approved amount as payment in full, (unless the ambulance transports you to a critical access hospital (CAH) or other center owned and operated by a CAH).

When does Medicare pay for ambulance service?

Emergency services

Medicare Part B covers ambulance services to or from:

  • A hospital
  • A critical access hospital (CAH)
  • A skilled nursing facility (SNF)
  • Dialysis facility
  • Although a physician’s office is not a covered destination, a temporary stop may be covered without affecting the coverage status

Transportation, when Medicare covers it, is only to the nearest appropriate medical facility that’s able to give you the care you need. So for instance, if you have an emergency but don’t wish to go to hospital A but it is closer to where you are at the time of the emergency than hospital B, Medicare will cover transportation to hospital A. If you choose to go to hospital B, Medicare will make a payment based on the charge for transportation to hospital A and leave you with the remainder of the bill. If no local facility exists, Medicare will pay for transportation to the nearest facility outside your local area that can provide appropriate care.

However, Medicare only does so if the supplier meets Medicare ambulance requirement and:

  • Another form of transportation could endanger your health
  • You must lie flat or be otherwise immobilized or are incapable of sitting up unassisted
  • You require a service such as intravenous drugs (and in some cases oxygen use) that are available in an ambulance but not in a car, taxi or Medi-car.
  • You have End-Stage Renal Disease and need dialysis and ambulance transportation to or from the dialysis facility
  • You require restraints

Let’s first understand what Medicare means when it says it will pay for transportation only if other transportation could endanger your health. An obvious example of this would be a heart attack or a stroke since you might need skilled medical treatment during transportation. If you’re bleeding heavily, unconscious or in shock, you would also qualify for transportation. Chest or abdominal pain, headache, dizziness, loss of consciousness or a nosebleed could be symptomatic of a more serious condition and would also meet these criteria. A broken bone usually wouldn’t qualify for a return trip for instance but might qualify for the initial trip if the fracture required immobilization.

Medicare might also pay for airplane or helicopter transportation based upon your health condition and obstacles to reaching a hospital in a timely manner such as if the distance is great, there is heavy traffic or a difficult pickup location.

Non-emergency services

Medicare considers situations when your health is in serious danger and every second counts to prevent your health from getting worse as an emergency. We think of ambulance transportation as a response to an immediate crisis but there are other times transportation by ambulance might be required and thus paid for by Medicare. When your life is not in danger, Medicare coverage of ambulance service is very limited.

Non-emergency ambulance transportation may meet Medicare’s requirements if such transportation is needed to obtain treatment (such as for dialysis) or to diagnose your health condition and any other type of transportation would endanger your health. A written order from your doctor must state that ambulance transportation is necessary due to your medical condition.

Times you might be covered for non-emergency ambulance service include:

  • Being bed confined and unable to sit in a chair/wheelchair and unable to walk
  • When you need vital medical services that would only be available in an ambulance such as administration of medications or monitoring of vital functions

A patient who is bed confined might have severe generalized weakness, contractures that prevent sitting, or immobility of lower extremities in a patient who is unable to be moved by wheelchair. Bed confinement is not automatically sufficient for Medicare coverage. It is an aspect of your condition that may be taken into account.

Medicare frequently denies payment for non-emergency transportation because Medicare regulations require the patient to be bed-confined. To meet the criteria for bed confinement, you must:

  • Be unable to get up from bed without assistance
  • Be unable to ambulate AND
  • Unable to sit in a chair or wheelchair

Lack of transportations alternatives does not justify Medicare coverage. Nor will Medicare cover the cost of non emergency transportation in a wheelchair accessible van.

When problems arise

According to the Center for Medicare Advocacy, one problem that occurs frequently is when nursing staff attempt to help ambulance staff by preparing the client for transport. In preparing, staff might assist the patient with getting dressed, pack their belongings and transfer the patient to a chair or recliner. When the ambulance crew arrives, their documentation does not indicate that the patient was unable to walk unassisted, was in a reclining position (rather than a sitting position) and required assistance for transfer. Because of the absence of specific communications, Medicare may eventually deny the claim. Such cases can be won on appeal but as pointed out at the beginning of this article fixing the error could conceivably take years.

To avoid such a situation discuss transportation options with a doctor or nurse prior to transport. If you are not bed confined, consider other forms of transportation. If transportation by ambulance is necessary, request that the doctor or nurse communicate the reasons clearly to the ambulance crew so their documentation will reflect the need.

If Medicare doesn’t cover an ambulance trip you believe should be covered, carefully review your Medicare Summary Notice (MSN) and any other paperwork related to your ambulance bill for errors in the paperwork that can be fixed. If Medicare doesn’t cover the trip and you believe it should, you have the right to appeal the decision. Carefully follow the directions on your MSN, sign it and send it and any letter you want to send explaining why you believe the trip should be covered, to the address on the MSN. A doctor or health care provider may be able to provide additional documentation to help your case. Be sure to copy everything you send to Medicare as part of your appeal. The Center for Medicare Advocacy offers detailed instruction on how to do this on their site.

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