Investigations

EMS in crisis: Patients pocketing insurance checks

CARLISLE, Pa. (WHTM) - Cumberland Goodwill EMS in Carlisle responds to more than 10,000 calls a year to help people in crisis, but it's facing its own crisis.

"We lose money every time we go out the door," Assistant Chief Nathan Harig said.

EMS services already struggle with low reimbursement rates from Medicaid and Medicare. On top of that, add patients pocketing insurance checks.

"In 2017, that number was about $176,000, just patients pocketing the money, and this year, as of the end of September, we were already at $177, 000. We see those numbers go up around the holiday season," said Harig.  "An average EMT salary in this area is about $50,000 a year, so we are losing the equivalent of three EMT's pay."

EMS services are considered out-of-network, so the law allows the insurance company to write the check directly to the insured.

"This is something we have certainly heard about in the bureau," said Dylan Ferguson, director of the state Health Department's Bureau of Emergency Medical Services.

The bureau doesn't regulate insurance, but it does provide oversight and support to 2,000 EMS services in Pennsylvania. 

"The General Assembly passed Act 84 in 2015 which did create an option for EMS providers to engage in agreements with insurers to be able to receive that direct pay," said Ferguson. 

The effort was not successful.

"In the first full year of the program, 23 services chose to participate. There were varying degrees, I would say, of success. I can tell you that this next calendar year, to date we have had no agencies notify us of their intent to take an election and participate, " said Ferguson. 

There is an effort to look at this issue again. Senate Resolution 6 formed a commission that is looking at how to improve both fire and EMS services. Direct pay is a part of that discussion. The SR6 Commission is expected to release its recommendations in a few weeks.

Meanwhile, EMS services are doing what they can to collect payment. 

"Oftentimes, it just goes to the debt collection process and the worst thing we can do is ruin their credit score," said Harig.

There may be another option. In Somerset County, 12 people were charged for not using insurance funds for ambulance services. ABC27 reached out Cumberland County District Attorney M.L. Ebert to see if he would consider criminal charges.

"I would be open to examining the factual background to determine if it would be suitable for criminal prosecution," Ebert said.

Insurance companies argue they want to encourage EMS to become providers so they can negotiate better rates for members. EMS services say the negotiated rates don't cover costs.

Until there's a change in the law, insurance companies can continue to write checks to members.

"In those cases, the [insurance companies'] obligation is to the patient, to their enrollee to pay what they have promised under the term of their insurance policy for the service that consumer received and it is the consumer's responsibility to pay that out-of-network provider and in this case an ambulance," Pennsylvania Insurance Commissioner Jessica Altman said.


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