posted July 12, 2017

A quick response is essential after a stroke, yet insurers often balk at the bill. Air Methods is there to help.

Karen Espinosa knew something was wrong, but in her confusion the word “stroke” never occurred to her.

The Lake City, Florida, woman kept dropping the shampoo bottle as she showered. She fell in her bedroom and struggled to get up. And when her daughter phoned from Switzerland, she found she couldn’t speak.

Fortunately, her daughter called the Lake City police to report what turned out to be a stroke. The first responders knew that “time is tissue” and called upon Air Methods to transport Karen by air to a hospital in Gainesville for advanced care that saved her from severe disability.

Yet when her insurance company paid her hospital bills, it refused to cover the full cost of the helicopter flight.

That’s where Air Methods’ Patient Advocacy program kicked in. The company provided an expert who helped Karen’s husband, Alan Espinosa, get through the maze of red tape to a full reimbursement.

“I’m not sure I would have found my way through it on my own,” Alan, who has worked in the EMS industry for several decades, said. “John, my patient advocate, really knew how the system worked, and he explained things to me about private insurance and insurance claims that, frankly, I’d never heard before.”

Espinosa’s case highlights a paradox regarding medical evacuations in stroke cases. Quick action saves brain cells and lives, but insurance companies often fight to avoid making full reimbursement.

Although the government reimburses hospitals for 94 percent of the cost of providing emergency care to the indigent, companies that fly the injured to those hospitals get less than 40 percent, on average, for these calls, says Paul Webster, Air Methods’ vice president of payer strategy.

That shifts the burden onto insurers, who often reimburse at a fraction of the cost, leaving patients facing financial peril when they are their lowest point physically.

“We are not prescreening who we’re transporting,” Webster says. “We are responding to every call that we get.”

Quick response all around.

Karen’s daughter, April, called twice before her mother was able to swipe her mobile phone and pick up the call. With April on the line, Espinosa found her way to her desk and tried to turn on her computer to get to Skype.

She felt a sense of disassociation. Though she is a nurse herself, the thought that she was having a stroke never occurred to her impaired brain, whose blood supply was partially blocked by a blood clot in a vital artery.

April stayed on the phone, crying as she said, “I love you. Don’t worry, Mom, the ambulance is on the way.”

Karen wanted to reassure her daughter, but she couldn’t get the words out. From Geneva, April phoned her father, who rushed to assess her symptoms.

“She had just a blank stare on her face,” Alan said. “It was obvious she didn’t understand what I was saying.”

An ambulance transported her to a nearby field, where she could be taken via medevac to North Florida Regional Medical Center in Gainesville.

“Air medical transport is essential to rural communities,” Alan said. “There are very few conditions that are as time-sensitive as an stroke. So, being able to get a patient to the stroke center where they can receive definitive care very rapidly plays a huge role in the outcome of that patient.”

Blood flow stopped.

Karen arrived at North Florida Regional Medical Center unable to speak or understand what was going on, said Cynthia Combs, stroke coordinator. Her medical team found a clot that stopped the blood flow to a large portion of her brain, and they threaded a hair-thin catheter through a vein and suctioned out the clot.

“She immediately, on the table, began to understand and began to speak,” Cynthia said.

Karen recalls asking, “Are they done?”

Cynthia replied, “Yes, they’re done. They got it.’”

Five or 10 years ago, Karen would have ended up in a nursing home after such a severe stroke, Cynthia said. But newer treatments and the quick response made possible a full recovery.

As someone who works with stroke victims, she has seen how it can leave people severely disabled. “I’m so lucky to be talking,” she said.

Karen returned to work within 10 days.

The bill, however, came as a shock. The insurer quickly covered all of the $187,000 hospital bill, except for an out-of-pocket expense of $3,400, but it balked at covering the helicopter transport.

“I was getting nowhere with the insurance company,” Alan said.

Air Methods patient advocate John Laudadio phoned Alan to offer help. He helped the Espinosas strategize, told them how to write a written appeal, and joined Alan and the insurer on the line for conference calls. He explained procedures and helped nudge the case along when it seemed to have fallen between the cracks.

The outcome: On the third appeal, the insurance company agreed to pay the bill in full.

“I really love to create some sort of bond letting patients know that they’re important and that we’re there to help,” John said.