Yesterday, the New York Times published an article about a COVID-19 patient in Pennsylvania who was transported by Air Methods. After the transport, the patient’s health insurance company, Independence Blue Cross, denied coverage for the COVID-related transport and medical care. The article incorrectly identified Conemaugh Medstar as the Air Methods partner that transported the patient, when in fact it was an air medical aircraft out of New Jersey.

We worked closely with the patient and her daughter throughout the claims process and provided the guidance that ultimately led to the claim being resolved. The patient’s daughter communicated with Air Methods and Independence while her mother recovered, but became concerned when Independence said they would not provide her with any information on the status of her mother’s claim. During that same time, Air Methods committed to working with both the patient and their insurance to get the claim resolved. We have set up a robust patient advocacy program to address such issues with insurers, as they happen often.

COVID-19 has hit healthcare providers particularly hard, including Air Methods. While many health insurers are reporting record profits during the pandemic, most health providers have been relying on CARES Act funds to make it through these difficult times, while continuing to serve every patient who needs us. As a recipient of CARES Act funding, Air Methods does not balance bill any COVID-19 patient and made that commitment even prior to receiving those funds. 

It is also important to note that, despite our efforts, Independence Blue Cross has refused to go in-network with Air Methods, or any air medical service provider not affiliated with one of its partner hospitals. The company is an outlier in our negotiations with Blue Cross and Blue Shield plans, as we have had success going in-network with many of them throughout the U.S., including plans in Pennsylvania, Maryland, New York, and Virginia.

Complications like these could be avoided if Independence Blue Cross – along with the big three national health insurance companies: Aetna, CIGNA, and UnitedHealth – would negotiate in good faith with Air Methods and include us in their network of providers. But until they do so, insurance will continue to force their customers to go through their arduous appeals process. 

The New York Times reporter reached out to Air Methods with a series of questions that we responded to in detail. Unfortunately, most of the information we sent her was not included in the article.

In the interest of transparency, we have decided to share the responses that we provided the reporter in full. We think this is important because it shows the level of detail that we shared and demonstrates Air Methods’ dedication to working directly with patients to resolve all billing issues.

The questions the reporter sent to Air Methods, and the responses we provided to her, are below:

1. Approximately how many coronavirus patients has Air Methods transported during the coronavirus pandemic? How many patients does Air Methods fly in a typical year?

Air Methods flies about 70,000 patients every year. Since the pandemic began, we have flown 3,300 suspected coronavirus patients.

2. Has Air Methods instituted any new billing policies related to coronavirus?

We publicly stated months ago, even before the CARES Act passed, that we created a special process for handling all COVID-19 patients and that we would not balance bill COVID-19 patients. Air Methods has remained committed to that practice.

3. How does Air Methods set the charges for inter-facility transport?

The cost of this around-the-clock readiness averages nearly $3 million per year for each air base. Further, approximately 85 percent of costs are fixed costs associated with operating an air base, giving companies little leeway in reducing costs on their own. And then, the payors set reimbursement rates for our services. We have no control over the number they settle on. We must appeal and/or negotiate the claim with the payor to receive a fair reimbursement. However, reimbursement for air medical services has not kept up with costs. Medicare, which covers air medical services in emergency cases only, established the current air medical service payment rates in 2002 based on an estimated 1998 cost pool. Today, the average Medicare per-transport reimbursement covers approximately half of the cost per transport, according to a cost study prepared for the Association of Air Medical Services (AAMS). Medicaid, on average, covers barely 30 percent. With the government insurance programs, Medicaid and Medicare significantly underpaying for transports, and uninsured patients paying very little (or nothing at all) for our services, any uncollected costs from those flights must be picked up by commercial payors.

4. Air Methods currently faces, by my count, six class action lawsuits in different states. Can you provide any comment on those lawsuits, which generally allege expensive fees and aggressive debt collection tactics?

While we cannot speak to the specifics of ongoing litigation, most of these lawsuits related to transports and associated billing are between six tp eight-years-old. Since that time, Air Methods has changed the way we do business, especially as it relates to the aftercare of our patients. For the past three years-plus, Air Methods has made it a priority to partner with insurers all over the country to develop in-network agreements that eliminate the possibility of a patient ever receiving a balance bill. We have seen a good deal of success and are now in-network with more than 50 insurers throughout the United States. We have also implemented a Patient Advocacy program through which we work directly with our patients’ insurance companies to coordinate reimbursements. This keeps patients out of the middle of the billing process, which can be confusing and stressful, especially while recovering from a serious medical issue. The average patient out-of-pocket cost for our patients is $167, which includes co-pays/deductibles. While Air Methods is in-network with nearly 50 percent of our commercially insured transports, it is our goal to be in-network with 100 percent. We have contracted with almost every payor in the markets we serve but have been unable to get Aetna, Cigna, or United to contract with us despite offering them lower rates which means their members remain stuck in the middle. In an effort to remove the patient, we are proactively contacting and signing agreements directly with employers who have health insurance coverage with Aetna, Cigna, or United to ensure that their employees have coverage for emergency air medical services. 

5. Approximately how often does Air Methods pursue debt in court? Does Air Methods use garnishments and liens to collect debt? I came across one case where Air Methods pursued a $53k garnishment from a patient’s bank account and wanted to know whether that type of debt collection is common or uncommon for the company.

We do not use liens or garnishments to collect debt. There was, unfortunately, a time when Air Methods pursued debt through garnishments and liens. But that approach has been eliminated from Air Methods’ processes when pursuing reimbursement from health insurance companies. It is clearly an ineffective way to settle billing issues and we have no desire to put our patients through that stress after we have transported and treated them.

There are only two reasons we will refer a patient’s account to a third party billing agency. If a health insurance company directly provides the payment to the patient rather than us, the medical provider, and the patient doesn’t use such payment to pay for medical services rendered. Unfortunately, many times insurers tell their customers to hold onto the payment. The only other instance that would cause us to send a patient to a third party billing agency is if, after a number of attempts and at least 120 days, the patient is non-responsive to our calls/communications asking for insurance status after the flight, which allows us to assist them with their health insurance company to get their bill resolved. We assist patients by assigning a Patient Advocate to every individual we have transported whose insurance will not pay their bill. Patient Advocates work with patients after they have been transported to help guide them through the billing process and advocate on their behalf when insurance companies that are not in-network deny a claim. 

6. In this story, I am looking at a $52,511 bill received by a patient who was inter-facility transported due to her coronavirus worsening. The patient was transported by Conemaugh Medstar, one of Air Methods’ subsidiaries. I attached that bill to a previous email for your review. Would you like to provide any comment on this case in particular, how the charges were set, and how the decision to bill [the patient] was made?

To be clear: We never sent a bill to [the patient], and our Patient Advocacy team assisted her through the entire insurance reimbursement process, which can be very confusing for our patients and their families. The outreach you referenced was the second communication from us to [the patient and was an update on where things stood with [the patient]’s insurance company, Independence Blue Cross Pennsylvania.

We have worked closely with [the patient]’s daughter since [the patient] is still in the hospital. She was incredibly helpful as her mother recovered and she did all she could to keep us updated on where things stood with their health insurance company. Independence Blue Cross initially provided a check that covered a small portion of the transport costs. Then, on June 24, [the patient]’s daughter reached out to tell us Independence was “not cooperating” with her family and that the reps from Independence would no longer discuss [the patient]’s case with her daughter nor with [the patient]’s husband either, who is the policy holder.

We told [the patient]’s daughter that we would assist the family with the underpayment appeal with Independence Blue Cross. We explained we would work with her and her family every step of the way, as [the patient continued to recover in the hospital. However, that same day, [the patient]’s daughter responded and told us Independence had informed her the initial reimbursement check was voided, and that the Independence rep would not share any additional information with her. We then reached out to Independence and a rep informed us that the claim had been denied because [the patient]’s plan “does not provide coverage for this service.”

After we learned that Independence had denied the claim, we reached back out to [the patient]’s daughter informing her that we would work with her on the appeal regarding this unfortunate denial of service. About a week later, [the patient]’s daughter told us she had spoken to an Independence rep, who told her the claim had been reevaluated and that a check would be sent to cover the entire cost of the emergency air medical transport provided by Air Methods. On August 11, we received an email from [the patient]’s daughter stating she had received a check from Independence for the full reimbursement, and she planned to mail it to us. 

The above process illustrates that we do not bill patients whose claims have been denied by their health insurance plans. It is truly unconscionable that, in this case, [the patient, a COVID-19 patient, has her insurance company issue payment for only a small amount, then the insurance company pulls it back and voids the payment by denying the services, then it reevaluates the care and, finally, pays the for the entire cost of care that Air Methods provided. This all could have been avoided if they would have done their due diligence in understanding that the patient had COVID-19 and/or they would go in network with air medical services. For our part, our Patient Advocate teams work closely with our patients to ensure they have guidance through the reimbursement process. We do this so that they are not alone in figuring out the steps that need to be taken. [the patient]’s family was incredibly cooperative throughout the entire process, and we are grateful [the patients recovering and that we were able to assist her in resolving this claim.

7. Has Air Methods or any of its subsidiaries received any funding from the Provider Relief Fund in the CARES Act? If so, how much?

Air Methods has received funding from the Provider Relief Fund in the CARES Act.

Follow-up question from reporter: I’m a little confused though by the statement that you never sent [the patient] a bill. The document dated June 1 has a box that says “amount due” and offers various methods of payment, a website to pay at, etc. Why shouldn’t that be considered a bill? 

The response is a bit long, but that is because this process becomes complicated when payors deny a claim for Air Methods’ emergency air medical transports – even when the transport is for a patient with complications due to COVID-19. Air Methods’ Patient Advocacy program is in place just for these situations – we are committed to walking our patients through this process and making sure they understand the steps being taken to resolve the claim so that they can focus on their recovery.

There are several reasons why the letter referenced in the story isn’t a bill. If the letter was the only correspondence the patient received, without any further guidance or explanation, we certainly acknowledge that it would be confusing. However, it was only one communication among many, over many months.

The letter referenced in the story was actually the second one Air Methods sent [the patient, and both of them explained that we were asking for her assistance in resolving the claim with her insurance company. We had already been in communication with [the patient]’s daughter where she advised us that they were expecting a reimbursement check from [the patient]’s insurance company, Independence Blue Cross Pennsylvania, prior to the letter dated June 1 was sent with that context in mind as [the patient]’s daughter planned to send that check to us as we worked with Independence to secure the remainder of the reimbursement. However, Independence then abruptly voided the check and told [the patient]’s daughter they would not share any additional information with her about the claim. [the patient]’s daughter then reached out to us and said Independence was “not cooperating” with her family and that the reps would no longer discuss [the patient]’s case with her or [the patient]’s husband, who is the policy holder.

This was all occurring as [the patient] was still recovering in the hospital. The letter we sent dated June 1 was sent after one of our patient advocates had already established communication with [the patient]’s daughter and explained how we would help her through the billing process with Independence. However, after the June 1 letter was sent, we then spoke with [the patient]’s husband on June 3 and he advised he was calling Independence to get the status of the reimbursement. Later that same day, [the patient]’s daughter called us and let us know she had spoken with the payor and had been told the claim was still in process. All of this background is to say, we are committed to communicating with our patients throughout the post-transport insurance process, and our goal is to ensure they have a clear understanding of that process. We spoke with [the patient]’s daughter several times throughout the summer. At no time did we give her the impression, nor do we believe she had the impression that we were pursuing payment from [the patient]). We were seeking payment from Independence Blue Cross Pennsylvania. If it were up to us [the patient] and her family would never have had to go through this process, which is established by the Independence Blue Cross Pennsylvania. The fact that she did is very unfortunate and Air Methods and our Patient Advocates do all we can to make it as easy as possible by working with the insurance company directly so patients like [the patient] and her family don’t have to.

Without the context of the many productive conversations we had with the [the patient]’s family, we acknowledge this one piece of communication (the letter) could be misconstrued as a bill. But it is not a bill and we believe [the patient]’s family fully understood that because we were in regular communication with them. What’s more, the goal of Air Methods is to go in-network with 100 percent of the health insurers in the U.S. to avoid these long, drawn-out situations that ultimately result in Air Methods receiving payment from the health insurance company anyway. It raises an obvious question: Why go through this long, drawn-out process in the first place? If payers – like Independence Blue Cross Pennsylvania, as well as the large health insurance companies like Aetna, Cigna, and UnitedHealthcare – would simply come to the table and negotiate with us, patients like [the patient] would not have to go through what she went through. For now, because this is the process dictated wholly by the health insurance companies that control whether these transports are covered, we do all we can to guide our patients through it. Obviously it’s a very complex situation, and one letter among months of communication certainly cannot tell the full story in any meaningful way.