$7000 per mile. That’s an absurd ambulance healthcare claim!
We often talk about the many billing issues that ambulance services encounter. In fact, it’s a frequent enough occurrence that we have services solely focused on our expertise in auditing these charges. So, it’s no surprise that we have a Lost Benjamin Award nominee highlighting this industry problem.
This Month’s Lost Benjamin Award Nominee
One of our large individual claim recoveries involved a ground ambulance claim originally paid at $700,000. The claim should have been paid at approximately $2,000! Our comprehensive audit process found the high dollar claim (can you imagine if a random sample review didn’t find it?!) and our expertise allowed us to quickly realize that it was unreasonable.
An ambulance claim involves two components: a base rate and a charge for mileage. Base rate is billed at a unit count of “1.” The mileage is billed based on the number of miles. In this case, the claim was incorrectly billed at over 100 units of base rate. In actuality, this was the number of miles!
To compound the issue, the TPA incorrectly considered the ambulance provider as in-network with a contract rate of 100% of billed charges. In fact, an out-of-network limit should have applied. The claim was eventually corrected with $698,000 returned to the client’s bottom line.
We Work with Ambulance Providers
Our audit approach captures all such claims for review and repricing at reasonable amounts. Our familiarity with the industry, along with long-standing professional working relationships, allow us to approach air ambulance providers with a fee negotiation agreement that allows fair reimbursement for services rendered that is often much lower than the full billed charge amount. In fact, our President Randy King addressed this topic in an industry article in 2007! You can read his tips here. Successful negotiation provides savings to the self-insured plan and eliminates any balance billing to patients as the providers agree to write off the difference between billed charges and the negotiation amount.
Thankfully the new No Surprises Act is designed to prevent individuals from being held responsible for the balance owed between out-of-network charges and the negotiated payment. However, self-insured employers need to continue to negotiate better rates so they are not left holding the bag. (You can read an informative article on this topic from Randy here.)
The bottom line? You need to have a plan to manage and audit ambulance services. We can help.
Healthcare Horizons is a leading expert in providing healthcare claims audit services, identifying overpaid or erroneous claims through its 100% Difference model, and recovering millions of dollars for clients’ bottom lines with uncompromising ethics and accuracy. Since 1999, the Knoxville, Tennessee-based company has provided superior healthcare claims audits for the world’s largest self-insured employers, involving all national payers. We have successfully identified and facilitated the recovery of millions of dollars of overpaid claims for employers.