A hospital administrator recently informed me that his hospital-based EMS is reimbursed by commercial insurances at 80% of actual charges. With above-average charge levels, insurance payments are double those of non-hospital EMS providers. At the same time, non-hospital providers are paid at or near Medicare allowables by some insurances, leaving many struggling to keep the doors open. Hospitals may gain an advantage due to excellent negotiating skills or simply sheer size. This is unlikely to be an isolated case. The hospital bills for EMS using a typical "Part A" format, or UB04 form. According to the administrator, billing in a "Part B" format (CMS1500) would reduce payments to the level of non-hospital EMS. Medicare reimburses the hospital according to the ambulance fee schedule, so the disparity seems to exist only with the commercial insurance sector. It seems peculiar that the insurance industry would continue this practice with hospitals, while being frugal with everyone else. Maybe the strong and unified voice of non-hospital EMS can someday result in a more equitable system.

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It actually makes perfect sense. Insurance companies are contracting with the hospital for the ambulance transport, in addition to numerous other services offered by the hospital. Compared to the cost of numerous other procedures and tests performed by the hospital, the EMS transports are going to make up a small share of that cost, and something that is much less worth fighting over. Ambulance services are often one trick ponies. Hospitals aren't, and if the insurance company loses too many hospitals in a given area, then they will start to lose subscribers.

Well it confuses hell out of me.

Hospitals typically contract for bundles of services with private insurance companiess.  All prices are negotiated - which is why, when you have a stent put in, the "bill" or that the patient sees is $17,000, but the insurance company settles in full for $3,000.


Non-hospital ambulances typically don't have contracts because they are such a small element.  So the insurance companeis decide what they will pay on their own.  The good news is that unlike Medicare, the ambulance company is free to go after the patient for the remaining balance, whatever it is.


It doesn't really have to do with the "form" used for billing, it has to do with the contract or lack thereof.  The form is just the medium by which the deed is done.


Small non-hospital ambulance services just don't have anything to negotiate with - we're "one trick ponies" with no leverage.

Skip Kirkwood said:

 Small non-hospital ambulance services just don't have anything to negotiate with - we're "one trick ponies" with no leverage.



Consider the example of Anthem insurance. A non-hospital ambulance service can contract with Anthem and receive direct payment, equivalent to Medicare rates. Without a contract, Anthem always send the check to the patient, as a matter of policy. In the current economy, recovering full payment from the patient can be an exercise in futility. Legislative efforts to require direct payment, with or without contract, have been unsuccessful. At the same time, hospital-based EMS is paid double that of everyone else.

Hospitals have leverage and the insurance industry has lobbyists. Which brings me back to my original point. Until there is a unified effort by the non-hospital ambulance industry, equitable reimbursement is an unattainable dream. The various associations, focused solely on their individual public or private sectors, have not gotten the job done.

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