Medicare and Medicaid only pay if there is medical necessity to be transported to a hospital by ambulance. Occasionally people fall within their home and call 9-1-1 or push a medical alert alarm for help. If the ambulance comes to your residence, we will assist you to a chair and provide a medical screening to determine if it is necessary to go to a hospital by ambulance. Medicare does not pay for the assessment or us coming to assist you, there will be a charge assessed to the person by the municipality.
Medical necessity is established when the patient's condition is such that use of any other method of transportation is not appropriate.In any case in which some means of transportation other than an ambulance could be used without endangering the individual's health, whether or not such other transportation is actually available, no payment may be made for ambulance services. This generally means the patient must have an acute injury or illness.
It is important tonote that the presence (or absence) of a physician's order for a transport by ambulance does not necessarily prove (or disprove) whether the transport was medically necessary.
The patient has the right to appeal this determination by contacting their insurance carrier directly.
Medicare: Ambulance transportation is a benefit included under Medicare Part B. Provided the transport meets medical necessity criteria and is a covered service, (Medicare does not pay for non-transport ambulance services or On Scene Care) Medicare will pay 80% of the legislatively regulated fee schedule after any applicable deductibles have been met. The remaining 20% is the patient's responsibility either to be covered by a supplemental insurance or private pay.
State Medicaid: Coverage requirements vary state to state and not all Medicaid benefit plans include coverage for ambulance services. You are responsible for providing your Medicaid information to our office for processing.
Commercial Insurance: For your convenience we will submit claims to private insurances including Health and Auto. We can only submit claims for which we have complete information including policy numbers, claim submission address, and group name and/or number (when applicable).
If wehave submitted your claim to your insurance and you are receiving this bill either 45 days has passed without a response or payment from your insurance or they have processed the claim and a balance remains or your insurance company has denied a portion of the charges citing above "usual an customary charges".
It is important to know that Ambulance Services are not regulated by " usual and customary charge " and you remain responsible for the entire balance.The rate structure utilized by your ambulance provider is not exorbitant by any means; their rates are based on annual surveyed averages of ambulance providers in their geographic area and most importantly by operational expense governed by the municipalities which own the service.
You can contact your insurance company to see what appeal or reconsideration options you can pursue to see if they will make additional payment..