Insurers Profit While Denying Claims Amid a Pandemic

The COVID-19 public health emergency has thrust our nation’s heroic health care workers into the spotlight, and deservingly so. Some of those heroes are less visible than others, though their work is no less important. The brave pilots, doctors, and nurses that staff emergency air medical flights have been providing an essential service throughout the pandemic and saving lives all over the country – from rural hotspots like Grand Island, Nebraska to the heart of New York City. Yet while the air medical industry is busy saving lives, some large insurers are busy putting profits over patients, refusing to cover the cost of COVID-19 testing and leaving patients recovering from the virus with a big bill.

Since the beginning of the pandemic, air ambulances have been transporting COVID-19 patients in respiratory distress to the nearest emergency room and providing inter-facility transports of intubated patients in order to relieve overcrowded hospitals, especially in rural areas.

While 100 percent of these transports happen at the request of a doctor or an EMT, some insurance companies are refusing to cover the cost, citing “medical necessity.” This is the same excuse insurers like UnitedHealthCare use for not covering the full cost of COVID-19 testing, making the distinction that they will only cover the cost of “medically necessary” testing.

This bad behavior did not start with the pandemic – insurers have been denying claims for air ambulance transport for years. What’s more, many large insurers refuse to bring air medical providers in-network, even though a Sierra Health Group study calculated that air medical services represent only $1.70 of a monthly insurance premiums.

This pattern of claim denial is even more unconscionable now. Millions of Americans have lost their jobs in the economic fallout of the pandemic, yet insurers are simultaneously reporting big profits. The cost of treatment for COVID-19 patients has been more than offset by the widespread cancellation of expensive elective procedures, like joint replacements, and Americans delaying routine care. U.S. health insurance profits have skyrocketed as a result.

Rather than leave patients in the lurch amid growing profitability, insurance companies must cover critical air medical transport services and, if they have not already, they need to enter into network agreements with air medical providers to negotiate a rate that is fair for both sides. Unfortunately, the big three national health plans – Cigna, Aetna, and UnitedHealth Group - refuse to even come to the negotiating table.

The National Consumers League, concerned with the insurance company denial of air ambulance transports, recently sent a letter to the CEOs of the three largest insurance carriers urging them to do just that. In their letter, they wrote: 

“We believe that emergency air medical transportation should be included in every health coverage plan. We think that insurance companies and air medical providers must work together to bring these services in-network, so patients are not left footing a bill they can never hope to pay.  Adequate network agreements are imperative so that patients are not told – after the fact – that they were transported by an air ambulance that was not in-network. When an emergency happens, or worse yet, a pandemic strikes, patients are not choosing whether to take an air ambulance, let alone choosing a particular provider.”

Early estimates indicate that air medical has provided over 4,200 transports of COVID-19 confirmed or suspected patients thus far. As cases continue to increase across the country, with the U.S. recently reporting its highest single-day increase in infections, even more transports will be necessary in the coming weeks and months. And when the pandemic is over, air medical will continue to be critical to victims of stroke, cardiac arrest, motor vehicle accidents and traumatic injury, particularly as rural hospitals close at alarming rates, leaving millions of Americans over an hour away from the nearest Level 1 or Level 2 trauma center.

Now is the time for insurance companies to step up and put patients first. As their profits soar during a national crisis, they should be more incentivized than ever to bring air medical services in-network, providing this critical service to their customers and saving lives in the process.

Congress Must Not Forget Air Ambulances in Next Coronavirus Relief Package

By Carter Johnson, national spokesperson for the Save Our Air Medical Resources (SOAR) campaign
Contact: media@soarcampaign.com

As America battles the global health crisis that has emerged from the rampant spread of COVID-19, Americans are showing their appreciation for the first responders on the frontlines saving lives. But it’s not just with nightly cheers for health care workers – Congress has also realized the urgent need to support this essential industry, earmarking $100 billion from the Coronavirus Aid, Relief, and Economic Security (CARES) Act to provide an influx of money to hospitals and other health care entities as they combat the pandemic.

Air ambulances are a vital part of ensuring access to emergency care in rural America, where hospital closures have left millions living an hour or more away from an emergency room or trauma center. As the coronavirus spreads inland to rural communities, air ambulances, equipped with ventilators and able to quickly deliver intensive care level patients to the most appropriate health care facility, are more important now than ever before.

As Congress and the administration continue to distribute emergency funding to health care providers on the frontlines in the battle against COVID-19, they must not leave air medical providers behind. The industry is facing unprecedented strain and needs the government’s support to continue providing critical, life-saving care. To do otherwise would be a grave mistake.

Thankfully, the Trump Administration recently reversed its decision and agreed to include air medical providers as eligible for reimbursement from the Public Health and Social Emergency Fund as compensation for treating uninsured COVID-19 patients. Yet while policymakers have responded to many of the needs of the health care community and have offered initial support to providers, including air ambulances, the payments do not reflect the significant costs and lost revenue facing air ambulance providers and suppliers in combating the COVID-19 public health emergency.

Early estimates indicate that the air medical industry has already transferred more than 1,500 confirmed and suspected COVID-19 patients. These are individuals with some of the most severe symptoms, such as respiratory distress, who do not have a second to spare and need immediate transport staffed by doctors and nurses who can treat them in the air.

The air ambulance industry is investing significant resources to combat the ongoing and predicted challenges of COVID-19, including investing in additional Personal Protective Equipment (PPE). At the same time, due to the impact of the stay-at-home orders people delaying emergency care and massive business closures, air providers, particularly in rural areas, are experiencing significant decreases in transports, adding additional cost pressures to these most critical areas. The Association of Air Medical Services (AAMS), in a letter to Health and Human Services (HHS) Secretary Alex Azar, has requested additional financial support to ensure the sustainability of the air ambulance community through the next six months, enabling providers to respond to critically ill patients.

If the coronavirus outbreak worsens and hospitals resort to furloughing employees due to their own financial challenges, air ambulances will be necessary not just to transport rural patients to hospitals, but to transport patients between facilities, as ICUs in underserved rural areas and urban hotspots may not have enough ventilators or beds to handle the influx of coronavirus cases. This happened recently in New York City, where a hospital evacuated 28 intubated patients in one night using air ambulances when its piped oxygen system became overwhelmed.

Compounding the challenges faced by air medical providers responding to the pandemic, over 75 percent of patients treated by air medical providers are either uninsured or have government insurance. Medicare and Medicaid reimbursement rates fall far short of the actual cost of service.

While the administration’s reversal on funding for uninsured patients is essential to the survival of the industry, we are not out of the woods. Air medical services are facing unprecedented strain and need the government’s support to continue providing critical, life-saving care. To turn the other way would be a grave mistake.

SOAR Campaign and Partners Send Letter to Congressional Leaders Asking for Air Ambulance Inclusion in COVID Relief Aid

WASHINGTON, DC – The Save Our Air Medical Resources (SOAR) Campaign, together with five patient and consumer advocacy organizations, sent a letter to leaders in Congress asking that air medical providers engaged on the frontlines of the fight against the coronavirus have access to critical resources provided in current and future COVID-19 relief legislation. 

In the letter, SOAR notes that air medical service providers are among the hidden heroes fighting against the coronavirus pandemic, transporting COVID-19 patients to the nearest appropriate facility for treatment and helping to relieve overburden hospitals with inter-facility transports. It is important that the air medical industry has access to critical resources provided to health care workers in any upcoming coronavirus relief legislation so that Americans can continue to have access to these life-saving services.

Below is the full text of SOAR’s letter to Congressional leaders:

June 9, 2020

The Honorable Nancy Pelosi                      The Honorable Mitch McConnell
Speaker                                                          Majority Leader

House of Representatives                         United States Senate
Washington, D.C. 20515                            Washington, DC 20510

The Honorable Kevin McCarthy                The Honorable Charles Schumer

Minority Leader                                            Minority Leader

House of Representatives                         United States Senate
Washington, D.C. 20515                              Washington, DC 20510

Dear Leaders:

As organizations focused on emergency health care access, particularly in rural America, we are writing to thank you for your continued support of frontline responders combatting the COVID-19 pandemic. We are a group of health care, consumer, and public safety organizations, as well as patient advocates, who appreciate the critical importance of emergency air medical services during this health crisis. As you continue to craft legislation and allocate funding to support health care workers, we ask for your consideration of these hidden heroes – those who may be less visible, but who are nonetheless integral in the fight against coronavirus.

Air ambulances, equipped with ventilators and highly trained medical staff, provide swift transport to the nearest hospital for patients in critical condition when every second counts. More and more often, this includes COVID-19 patients suffering respiratory distress or in need of inter-facility transport while remaining intubated. Early estimates indicate that the industry has transported at least 4,250 COVID-19 positive cases since the beginning of the pandemic, a number that will drastically increase over the next 12-18 months as the virus spreads to more rural parts of the country.

Air medical services are especially important in rural America where hospital closures have reduced access to emergency medical care for millions of Americans. As the coronavirus moves inland, air ambulances fill the gap left by these closures, transporting patients from overrun and under-equipped rural facilities to hospitals with the capacity to treat them. A recent example from Grand Island, Nebraska – a rural hotspot for coronavirus – reveals the massive increase in air ambulance transports taking place due to the virus.

Emergency air medical services also provide critical support to those who have suffered a major cardiac event, stroke, or trauma such as brain injury. In normal times, these patients account for 90 percent of those transported. These individuals will continue to need access to immediate emergency care even after the pandemic is over, and we must ensure the industry is there to help them.

We want to ensure air medical providers engaged in the frontline fight have access to resources provided by Congress in response to COVID-19. It is important that patients continue to have access to the life-saving services provided by air ambulances, and we urge you to help protect this critical service.

Sincerely,

Association of Air Medical Services

Brain Injury Association of America

Consumer Action

Helicopter Association International

International Association of Flight and Critical Care Paramedics

Save Our Air Medical Resources

Insurers Profit While Patients Access to Health Care at Risk

Christina Kanmaz, Spokesperson, Save Our Air Medical Resources (SOAR) Campaign

Tens of thousands of deaths, hundreds of thousands hospitalized, and almost complete economic disruption has led Congress to consider a series of relief packages aimed at helping the most vulnerable among us get through the COVID-19 crisis. While Americans will be feeling the pressure from the pandemic for months and even years to come, insurance companies are predicting they will face little to no financial impact from the pandemic. At the same time, access to emergency health care, especially for Americans living in rural areas, is shrinking and at risk.

As the virus migrates from densely populated urban areas to more rural parts of the country, access to emergency care becomes more difficult due to rural hospital closures. First responders like air medical providers fill the gap, so that individuals can access a higher level of care quickly, as rural hospitals or clinics often do not have the resources, equipment or expertise to care for these patients. 

While air medical is a key component of the health care delivery system, providers are also at risk of having to close bases. With the mandated stay at home requirements and individuals seeking urgent care all together, many providers have experienced a significant drop in revenue due to lower volumes.  Regardless of the volume of requested flights, air medical bases must be ready 24 hours a day, 365 days a year to respond to a call.

In addition, seventy percent of all air transports are covered by Medicare and Medicaid and reimbursement by these government programs is almost half the cost of delivering care. For those with private insurance, some companies refuse to go in network with air medical providers or deny payment for air transport due to “medical necessity” despite the fact that 100 percent of all flights are ordered by a first responder or medical professional.

And yet, recent reports show that private insurers stand to fair well in 2020. In their first quarter earnings reports, the country’s largest insurers revealed that COVID-19 had had no or little impact on their profits, despite the loss for many Americans of employer-sponsored health care coverage. Insurers account for this trend by pointing to reduced utilization by patients who are not seeking care during stay-home directives. Less utilization means more profits for insurers.

The National Consumers League, concerned with insurance company denials of air ambulance transports, wrote to the CEOs of the top three insurance companies calling on them to cover these life-saving services. They wrote:

“We believe that emergency air medical transportation should be included in every health coverage plan. We think that insurance companies and air medical providers must work together to bring these services in-network, so patients are not left footing a bill they can never hope to pay.  Adequate network agreements are imperative so that patients are not told – after the fact – that they were transported by an air ambulance that was not in-network. When an emergency happens, or worse yet, a pandemic strikes, patients are not choosing whether to take an air ambulance, let alone choosing a particular provider.”

Rural communities depend on air medical services and it is imperative that they continue to be available in a post-COVID world. Hospitals are central to the pandemic response, but they are just one piece of the health care delivery system. Transporting patients by air in rural areas, where access is a challenge even under normal circumstances, is also critical. It is estimated that air medical has flown at least 2,000 COVID positive patients since the pandemic began but the true number is likely much higher.    

As the country continues to navigate COVID-19, Congress cannot ignore the emergency air medical providers on the frontlines. What’s more, the insurance industry – especially as its profits soar – should be incentivized more than ever to go in-network with these air medical providers. Americans’ lives depend on it.

As COVID-19 Spreads In Nebraska, Air Ambulances Come To The Rescue

By Carter Johnson, spokesperson for Save Our Air Medical Resources (SOAR) 

A recent story by reporter Tim Johnson highlighted the increasing importance of air ambulances in Grand Island, Nebraska, a town which relied heavily on emergency air medical transports last month as cases of coronavirus exploded in this rural hotspot.

The case of Grand Island reveals a problem in rural America that has been growing over the past decade and has been magnified by the inland spread of COVID-19: our rural health care system is stretched thin, making it harder for patients to access the care they need. Luckily, as shown in Grand Island, the air medical industry is there to fill the gap.

Some 120 rural hospitals have closed since 2010 and several more are considered high risk and on a path towards closure. In fact, a recent study placed upward of 25 percent of Nebraska’s rural facilities in the ‘vulnerable category,’ meaning they are vulnerable to closure given their similarities to other rural hospitals that have closed since 2010.

Closures mean rural residents must drive an hour or more to reach the nearest emergency room or level 1 or 2 trauma facility. As anyone who has suffered a major cardiac event or stroke knows, in emergency situations, every minute counts. Air ambulances are essentially flying emergency rooms, equipped with life-saving equipment, and trained medical staff. They provide swift transport to the nearest hospital while treating the patient in the air, improving health outcomes.

In Nebraska, where over two-thirds of the population is living in rural areas, coronavirus cases are on an upward trajectory. Nearly 7,000 cases have been reported so far.  Air medical providers are increasingly on the frontlines of the fight against the pandemic in the state and around the country, ensuring access to medical care when it matters most for patients suffering severe respiratory symptoms, as well as providing inter-facility transport to ease the burden on rural facilities lacking in staff, ventilators or open beds to treat the influx of COVID-19 cases.

Air ambulance providers and suppliers, like all other frontline health care workers, have faced increased operation costs in the battle against COVID-19, including significant investment in PPE and increased time spent on decontamination of aircraft. Even before the pandemic, the industry was facing financial headwinds that resulted in 57 base closures last year alone. The companies forced to close their bases cite low reimbursement rates from Medicare and Medicaid, as well as insurers refusing to bring their services in-network and even refusing to cover the full cost of a patient’s bill, citing medical necessity. This dangerously threatens an industry that is only growing in necessity. 

Rural patients in Nebraska deserve access to the life-saving services that air ambulances provide. It is not just critical during this pandemic, but will remain critical for victims of stroke, cardiac arrest, and traumatic injury once it is over as well.

Congress must ensure that air ambulance providers can access resources intended to reimburse the health care industry in future coronavirus relief legislation. Insurers must also do their part and step up to cover the costs of care. Failure to act puts Nebraskans at risk.  

SOAR Campaign Statement on Policy Change to Allow Air Ambulance Industry to Recoup Funds from the CARES Act’s Public Health and Social Emergency Fund

“The SOAR campaign applauds the Trump Administration’s decision to allow the air ambulance industry to seek reimbursement from the CARES Act’s Public Health and Social Emergency Fund for the treatment of uninsured COVID-19 patients. Emergency air medical providers are on the frontlines of the public health crisis, providing critical care while transporting sick patients to the closest, most appropriate medical facility. In many rural parts of the country, where hospitals have continued to shutter, this means transporting patients farther to access the care they need. However, over 70 percent of those transported have either Medicare, Medicaid or no insurance at all, causing financial strain on providers. By acknowledging air medical’s status as ‘eligible health care providers,’ the industry will be able to continue providing this essential frontline service, especially for vulnerable American’s living in rural areas.” 

SOAR Campaign Statement on Insertion of Surprise Medical Billing Proposal in COVID-19 Legislation

Any attempt by Senate Health, Education, Labor and Pensions Committee Chairman Lamar Alexander (R-TN) and House Energy and Commerce Committee Chairman Frank Pallone (D-NJ)  to attach their proposed surprise medical billing language to the emergency COVID-19 Senate package is misguided and would hurt health care access when Americans need it most. As the nation copes with the impact of the global COVID-19 pandemic, policymakers must remain focused on protecting access to emergency medical care – particularly for our most vulnerable populations – rather than impeding it.

The proposed language forgoes any type of data collection necessary to find real solutions to the underlying cause of balance bills and provides an arbitrary threshold of $25,000 as a requirement to enter into any type of arbitration. This threshold compromises the ability of emergency air medical services to continue operations by eliminating any incentive for insurers to reach in-network agreements with air medical providers or pay the true cost of air medical care. The language prioritizes insurance industry profits over the health care needs of patients.

In a time of crisis, Congress must focus on protecting Americans’ health care access and reject any attempt to insert this deleterious language into the emergency COVID-19 package.

SOAR Campaign Statement on House Education, Labor and Workforce Committee’s Ban Surprise Billing Act of 2020

“The SOAR Campaign applauds Congressional action to address balance billing in a way that takes patients out of the middle and protects access to air medical services. Unfortunately, legislation under consideration in the House Education, Labor & Workforce Committee would do the opposite. The proposed language in the committee’s draft would allow insurers to continue maintaining narrow networks and denying patients coverage after emergency transports, and empower insurance companies to set one reimbursement rate for all air medical providers by negotiating with only a single provider.

Good work is being done in the House to address balance billing, however. Congress should follow the leads of the Ways & Means and Energy & Commerce Committees, both of which are advancing legislation that requires the collection of data from air medical providers and insurers so that reimbursement rates can be based on actual cost and claims. This approach is in line with the work of the U.S. Department of Transportation’s Air Ambulance and Patient Billing Advisory Committee, which is working diligently to meet Congress’s mandate to examine the underlying cause of balance bills and determine what data is needed to resolve this issue in a way that takes patients out of the middle and preserves emergency air medical service for all communities, especially in rural areas.”

SOAR Campaign Statement on Ways & Means Committee Consumer Protections Against Surprise Medical Bills Act of 2020

“The SOAR Campaign applauds the House Ways & Means Committee for including the collection of operational cost and insurance claims data from air medical providers in its proposed legislation on surprise medical bills. We’ve said all along that policymakers must evaluate real data if they want to address the underlying cause of surprise bills - denials by private insurers and the chronic under-reimbursement by government payers,” said SOAR spokeswoman Carter Johnson.

“When claims data is collected, they reveal insurer practices of denying claims, after the fact, for ‘medical necessity’ and network status. The collection of provider cost data sheds a light on the vast under-reimbursement by government programs, like Medicare, which has led to base closures across the country. This legislation, in conjunction with the work being done by the Department of Transportation’s Air Ambulance and Patient Billing Advisory Committee, are important steps toward taking patients out of the middle while preserving access to these life-saving services, especially for Americans living in rural areas.”

SOAR STATEMENT ON PROPOSED SURPRISE BILLING LEGISLATION AGREED TO BY THE SENATE HELP COMMITTEE AND THE HOUSE ENERGY & COMMERCE COMMITTEE

“The surprise billing legislation agreed to by the Senate HELP Committee and the House Energy & Commerce Committee puts in peril patient access to life-saving emergency air medical care. We have long been advocating for a fair and sustainable solution to surprise billing – based on data and cost of service – that would ensure patients are taken out of the middle and health care access is preserved. Unfortunately, lawmakers in both committees have decided to forgo any type of data collection and have instead agreed to support an arbitrary threshold of $25,000 as a requirement to enter into any type of arbitration.

This threshold compromises the ability of air medical services to continue operations by eliminating any incentive for insurers to reach in-network agreements with air medical providers or pay the true cost of air medical care. In addition, this federal government set rate only puts more pressure on air medical providers as Medicare and Medicaid already pay less than 40% of air medical costs. In 2019 alone, more than 57 air medical bases have closed, many of which served rural communities with already limited access to care. This agreement could lead to the closure of countless other bases throughout the country and put patient access to air medical services further at risk.

With this agreement, committee members have prioritized insurance industry profits over the health care needs of their constituents.”

SOAR and Partners Call on Congress to Oppose Sec. 105 of Lower Health Care Costs Act

Policymakers Should Preserve Patient Access to Emergency Air Medical Services

WASHINGTON, D.C.- In a letter to the Senate Committee on Health, Education, Labor, and Pensions (HELP), the Save Our Air Medical Resources (SOAR) campaign and its partners urged the committee to reject Section 105 of the Lower Health Care Costs Act, noting that it could limit access to air medical services for millions of Americans, especially those living in rural areas. The groups, which include the Brain Injury Association of America, Consumer Action, the Consumer Health Coalition, the Association of Air Medical Services, and the International Association of Flight and Critical Care Paramedics, called on Congress to look at the variety of factors affecting air ambulance costs in order to adopt a more comprehensive, data-driven solution to surprise billing issues.

###

Full text of the groups’ letter to the Senate HELP Committee:

September 16, 2019

Dear Chairman Alexander and Ranking Member Murray,  

We are writing to you today to urge you to protect and preserve access to emergency air medical services in S. 1895, the Lower Health Care Costs Act. Emergency air ambulances provide the critical care and quick transport needed to keep patients alive in times of medical emergencies. Air medical services are especially critical in rural communities, where hospital closures have significantly reduced access to care. Since 2010, more than 110 rural hospitals have shut their doors, which has left approximately 85 million Americans more than an hour drive away from a Level 1 or Level 2 trauma center.

Unfortunately, air ambulances have come under fire due to isolated, but highly-publicized issues related to patients’ surprise medical bills.

We agree that surprise medical billing must be addressed, and we appreciate the considerable time and effort your committee has dedicated to crafting S.1895. Although it was conceived with the best intentions, this legislation – most notably section 105 – will further restrict access to air medical services and cause more harm to rural communities.

Section 105 will allow insurance companies to pay air medical providers a median in-network rate. However, many insurers refuse to bring providers in-network in the first place or, in some cases, only bring in one emergency air medical provider. This means that insurers will be able to essentially set their own prices because an accurate median in-network rate cannot be set if there are no, or only one, providers in-network.

Arbitrary median in-network rates will do nothing to solve the issue of surprise billing. In fact, these rates are likely to result in even larger bills for patients with private insurance.

Currently, Medicaid and Medicare patients – along with those who are uninsured – account for more than 70 percent of all air ambulance flights. Despite the significant amount of deployments that these two programs are responsible for, both programs chronically under-reimburse the providers, leaving privately insured patients to cover the difference.

Dangerously low reimbursement rates impact more than individual patients; they also threaten the air medical industry as a whole. Since January 2019, 35 air medical bases throughout the country have closed leaving four million Americans without medical coverage within a ten-minute response time.

Surprise medical billing is a complex issue that must be addressed with comprehensive legislation based on thorough and accurate data from both providers and insurers. A variety of factors – including reimbursement rates which have not been updated in 20 years – impact the costs of air ambulance transports. We urge you to reject Section 105 and consider a more data-driven approach to this issue so that patient access to life-saving air medical services is preserved.

Thank you,

Brain Injury Association of America (BIAA)

Consumer Action

Consumer Health Coalition

International Association of Flight and Critical Care Paramedics (IAFCCP)

Alaska Center for Rural Health and Health Workforce

Save Our Air Medical Resources (SOAR) Campaign

Association of Air Medical Services (AAMS)

CC. Members of the Senate Committee on Health, Education, Labor and Pensions

SOAR Statement on the Department of Transportation Establishing the Advisory Committee on Air Ambulance and Patient Billing:

“We support the process established by Congress last year when it directed the Department of Transportation to collect data from the air medical industry and develop recommendations for protecting patients from balance billing, improving disclosure and informing consumers of insurance options. This is important work that must get underway immediately. Congress should not rely on anecdotes when crafting legislation to address balance billing, but rather benefit from real cost data so that it can address the underlying cause of surprise bills – the chronic under-reimbursement by government payers and private insurers. Only then will access to these life-saving services be protected and patients be taken out of the middle.”

Joint AAMS/SOAR Letter RE: Misleading Insurance Commissioners Letter of September 4, 2019

Link to letter found here:

Dear Chairman Alexander and Ranking Member Murray:

We agree that patients should not receive “surprise” bills because bad actors in the insurance industry force insured patients into reimbursement disputes that should be between healthcare providers and insurers.  We support efforts to ensure patients in need of emergency medical services across America, especially in rural areas where hospitals are closing at an alarming rate, have access to emergency air ambulance services without their insurance companies sticking them with the bill.   

Unfortunately, we find it necessary to correct three misleading accusations a number of insurance commissioners sent you in a letter on September 4th.

1. The laws in North Dakota did not affect access to care, because they were overturned by the courts.

The Commissioners claim that they have “learned from the experience of North Dakota,” where the legislature passed laws in 2015 and 2017 regulating air ambulance rates, but air ambulance providers did not leave the state.  

The Commissioners fail to mention that both laws were immediately overturned by the courts, as Mr. Jon Godfread, the Commissioner from North Dakota and lead signatory of this letter, should know well—he was the defendant who lost this case in January of 2019:

“The Court concludes, as a matter of law, that Section 26.1-47-09(3) of the North Dakota Century Code is preempted by the Airline Deregulation Act of 1978. . . . Congress has assumed the field in the area of air carrier regulation.  Insurance regulation remains the province of the states.  If the State wishes to protect patients who need air ambulance services it would do well to mandate insurance providers pay a larger percentage of the charges rather than trying to regulate how much the air ambulance bills for its services.”

Guardian Flight, LLC v. Godfread, 359 F. Supp. 3d 744, 755 (D.N.D. 2019) (emphasis added).

While this decision is under appeal, the industry is confident it will again be upheld, and this iteration of the law will be rendered permanently unenforceable.  North Dakota similarly lost in the courts over its 2015 law.  (See Valley Med Flight, Inc. v. Dwelle, 171 F. Supp. 3d 930, 947 (D.N.D. 2016)).

Air ambulance companies in North Dakota have made a business decision to accept temporary losses, on some flights, to ensure continued coverage for North Dakotans in need of emergency care, while this temporary issue was resolved.  That is very different from claiming a cap on emergency air ambulance reimbursement would not affect access to care in rural America.  Over 35 air medical bases have closed across the United States this year [2019] alone, most of them in rural areas, citing low reimbursement rates as the factor driving them to close.  Mandating lower reimbursement guarantees will cause many more to close.  

2. Air ambulance companies want to negotiate in-network agreements.  Some insurance companies simply refuse to enter those negotiations.

All of the major emergency air ambulance providers are working diligently to negotiate, in good faith, to go in-network with insurance companies around the United States, with marked success in recent years, while the Commissioners’ letter makes unsubstantiated claims to the contrary.  We have attached two examples of letters the emergency air ambulance industry has received from insurance companies refusing to even enter into negotiations for in-network agreements.  (See attached.)

3.      Insurance companies who deny critical emergency air ambulance transportation services create balance bills.

Emergency Air Ambulances only respond to requests that come from a physician or medically-trained first responder who determines the patient’s situation is so dire there is no other appropriate choice.  Almost half of all claims for out-of-network emergency transports are immediately denied for medical necessity, a business strategy some insurance companies use to negotiate lower reimbursement rates.

This insurance company denial or dramatic underpayment is the tactic that leads to patients receiving balance bills.  Insurance companies then force emergency air ambulance companies to work with the insured patient to appeal unreasonable denials for medical necessity to their insurance carrier.  Balance bills are not an air ambulance business model; they are a strategic decision by some bad actors in the insurance industry to avoid paying a reasonable rate for emergency services.

A Federal Solution should be balanced, and should encourage the market to work.

We agree insurance companies should not put insured patients in the middle of negotiations with healthcare providers by sticking them with balance bills.  We want to ensure people in rural America have access to trauma centers when their lives and future wellbeing are at risk.  As more critical access hospitals close across the United States, emergency air ambulances become the only link for people in those areas to reach life-saving emergency medical services in a timely manner. 

Instead of establishing arbitrary median in-network rates, data from both insurers and providers should be collected and analyzed. Meaningful and sustainable legislation can only be introduced once the real cost of service is known. An integral first step of this process is to begin the work of the Department of Transportation Advisory Committee as enacted by Congress last year, which we hope will be underway soon.

We support a federal solution that encourages the market to work and incentivizes both sides, insurance companies and emergency air ambulance providers, to come to the table to negotiate fair in-network agreements.  Unfortunately, the current language in the Lower Health Care Costs Act sets rates that will force more bases to close, further limiting access to emergency medical care in rural America.

We look forward to working with you on a solution that protects patients’ lives, ensures network adequacy, and protects patients from balance bills.

Sincerely,

Richard Sherlock                                                        Carter Johnson

President and CEO                                                     Spokesperson

Association of Air Medical Services Save Our Air Medical Resources Campaign

SOAR Campaign Applauds Lujan Amendment to No Surprises Act

Requiring Data Collection from Air Medical Providers and Full Transparency from Insurers Will Get to the Root Cause of Surprise Billing

WASHINGTON, D.C. – The Save Our Air Medical Resources (SOAR) Campaign today applauded Rep. Ben Ray Lujan’s (D-NM) amendment to the House Energy and Commerce Committee’s No Surprises Act (HR 3630).

The amendment would require the Department of Health and Human Services (HHS) and the Government Accountability Office (GAO) to collect cost data from air medical providers and claims data from insurers, and report to Congress on the overall cost of providing air medical services.

“To solve the issue of surprise billing for patients, policy makers must first look at real data and address the root cause – denials by private insurers and chronic under-reimbursement by government payers,” said SOAR spokeswoman Carter Johnson. “Air medical providers have long called on Congress to collect data to address these underlying issues. We applaud Congressman Lujan for recognizing the need for full data transparency, particularly from insurers, and encourage Congress to enact this amendment.”

When data on the industry has been collected, it has dispelled inaccuracies and misperceptions about balance billing within the air medical industry. A recent state of Wyoming’s Department of Public Health report shows that most air medical transport patients pay little or nothing for these emergency services.

“Thirty percent of all emergency air medical transports are for patients with private insurance and balance bills occur when a patient’s private insurer refuses to pay for the life-saving service,” said Johnson. “The State of Wyoming’s report demonstrates that anecdotal stories about large balance bills don’t measure up to the data. When Congress collects data about the industry on a national level, a similar trend will emerge, allowing for sound policies that will once and for all take patients out of the middle after insurer denials.” 

Consumer and Health Groups: Senate H.E.L.P. Legislation Could Limit Access to Air Medical Service for Rural Americans

WASHINGTON, D.C. -- In a letter to the Senate Committee on Health, Education, Labor, and Pensions (HELP), seven consumer, health and air medical organizations expressed concern over the bill’s unintended threat to access to air medical service in rural America. Specifically, the groups cited Section 105 of the Lower Health Care Costs Act, and noted that 32 air medical bases have already closed since the beginning of 2019. The letter urges the committee to instead address one of the root causes of cost-shifting to the private sector by updating the Medicare reimbursement rate for air medical services and having insurers cover these critical services.

Full text of the groups’ letter to the Senate HELP Committee is below.

July 16, 2019

Dear Chairman Alexander and Ranking Member Murray,

We applaud your work to address the problem of balance billing in the context of air medical transportation. This is a matter of great concern because today, approximately 85 million Americans, or 1 in 4, can only reach a Level 1 or Level 2 trauma center within an hour if they are flown by an air medical helicopter. In addition, 22 percent of rural hospitals have shuttered since 1990 and many more are on the brink of closure. Emergency care is becoming increasingly scarce, and thus air medical services are increasingly essential.

Ninety percent of emergency air medical transports treat patients experiencing a stroke, a cardiac event, or a traumatic injury. Air medical services are clearly needed and indeed, are often the only option for patients to get access to life-saving care quickly.

In this vein, we are concerned that Section 105 of the recently introduced Lower Health Care Costs Act, while undoubtedly well-intentioned, could inadvertently limit access to air medical services for millions of Americans, especially those living in rural areas. We recommend that Congress instead address the underlying problem by updating the Medicare reimbursement rate, which has not been changed in two decades.

More than 70 percent of patients transported by air ambulance have Medicare, Medicaid, another form of government insurance, or are uninsured. When government programs reimburse far below the cost of service, those costs are shifted, and balance bills increase for people with insurance. The balance billing problem must be addressed in a way that is fair to all parties – patients, providers, taxpayers who support federal health care programs, and insurance companies – and access to emergency air medical services must be protected for the 85 million Americans who, as noted above, currently can only reach a Level 1 or Level 2 trauma center within an hour if they are flown by an air medical helicopter.

There is an urgency to our concerns. Since January of this year, 32 air medical bases have closed. We urge you to look at the variety of factors affecting air ambulance service costs and reimbursement policies and take action to ensure that Congress adopts thoughtful, fair and comprehensive reimbursement and coverage rules. We thank you for your attention to this important issue.

Sincerely,                                                                                                  

National Consumers League

Brain Injury Association of America

Consumer Action

Consumer Health Coalition

International Association of Flight and Critical Care Paramedics (IAFCCP)

Association of Air Medical Services (AAMS)

Save Our Air Medical Resources (SOAR) Campaign

cc: Members of the Senate HELP Committee 

Wyoming State Report: Air Ambulance Balance Billing Stories Don’t Match The Facts

Policymakers Should Collect Data and Get to the Root Cause of Surprise Billing

WASHINGTON, D.C. – A recent state of Wyoming’s Department of Public Health report shows that most air medical transport patients pay little or nothing for these emergency services, dispelling inaccuracies and misperceptions about balance billing within the industry.

The May report analyzed balance billing by emergency air medical providers and provided policy proposals to take patients out of the middle. The report found that the average out-of-pocket payment for emergency air ambulance transports by patients with private insurance is $300, with approximately 90 percent of those patients paying nothing. According to the report, of the 10 percent who do pay something for their transport, the median amount paid is $700. This aligns with research conducted by Xcenda which found that the average cost paid out-of-pocket by patients is $600.

“Thirty percent of all emergency air medical transports are for patients with private insurance and balance bills occur when a patient’s private insurer refuses to pay for the life-saving service,” said SOAR spokeswoman Carter Johnson. “The State of Wyoming’s report demonstrates that anecdotal stories about large balance bills don’t measure up to the data.”

Americans think insurers should pay for emergency air transport. A survey by the American College of Emergency Physicians found that 81 percent of Americans believe their insurance companies should pay for surprise medical bills and more than half – 54 percent - of survey respondents said they received a surprise bill because their insurance did not cover the medical treatment they received.

“If policy makers want solutions to this issue, they must first look at real data and address the root cause – chronic under-reimbursement by government payers and denials by private insurers,” continued Johnson. “Seventy percent of emergency air medical flights are covered by Medicare, Medicaid or are for patients with no insurance. Medicare only reimburses 59 percent of the cost of transport and Medicaid on average only reimburses 34 percent. This has led to immense financial challenges for the industry, as evidenced by the 32 air bases that have closed across the country since the start of this year.”

Private insurers also deny reimbursement for these services. Approximately half of all air medical claims are denied by insurance companies, either on the basis of network status or medical necessity. This despite the fact that 100 percent of emergency transports are ordered by an EMT or attending physician based on medical necessity.

“The legislative remedies to balance billing currently under consideration in Congress, while perhaps well intentioned, are misguided. But there is a better way. Congress already passed legislation last year calling for the U.S. Department of Transportation to collect cost data from the industry and develop recommendations for protecting patients from balance billing. This process must be allowed to move forward, before harmful legislation can be passed that puts these services at risk. By working together to address private insurer and government payer reimbursement, we can take patients out of the middle and protect access to the care they need in an emergency.”

SOAR Statement on Chairman Alexander’s Remarks About Air Medical

The following statement was released today by Carter Johnson, spokesperson for the Save Our Air Medical Resources (SOAR) Campaign, in response to Chairman Lamar Alexander’s remarks pertaining to air medical during today’s legislative hearing on S. 1895 in the Senate Health, Education, Labor & Pensions Committee.

“This proposal is dangerous, unworkable, and puts patient lives at risk. 85 million Americans live in rural areas where it takes more than an hour to get to a Level I or Level II trauma center by ground. Air medical transport is the lifeline that delivers patients to the health care facility they need in emergency situations. This bill, which puts insurance companies ahead of patients and by letting insurance companies decide what they want to pay for this service, will decimate essential air medical services and leave patients without access to the care they need in an emergency.

“The concept behind benchmarking is simply unworkable when applied to air medical transportation because in most places, there is no meaningful median network rate. Some insurance providers have refused to allow any emergency air medical providers to go in-network, and others have only one in-network emergency air medical provider. Further, it is completely inaccurate to say that 70% of air medical transports are out of network — in fact, 70% of air medical patients are either uninsured or covered by Medicare, Medicaid or other Government insurance. Only 30% of air medical patients have private insurance coverage, and if one applies the GAO’s questionable estimate that 69% of this smaller group is transported by providers that are out-of-network, this represents about 1 in 5 air medical transports overall.

“These and other facts should raise concerns among policymakers about the notion of benchmarking. If 69% of the small group of patients who have private insurance are transported by air medical providers that are outside of their insurance network, isn’t it obvious that the data necessary for benchmarking are missing? How could appropriate rates be set without factoring hard data on rural vs. suburban transports, provider type (hospital system v. community v. standalone provider), type of transport, patient outcome, and patient claim experience, to name a few crucial considerations? This is policymaking in the dark with a blindfold.

“If this proposal becomes law and insurance companies are allowed to reimburse air medical providers at either an illusory median network rate or the minimum allowable rate, insurance companies will default to the minimum allowable rate, which is not based on negotiated market data or actual market conditions. The result will be that insurance companies will increase their profits, air bases will close, and millions of Americans will lose access to the care they need when they need it most.

“There is a better way. The government should get the data it needs before approving this dangerous and impractical proposal.  Last year, Congress directed the U.S. Department of Transportation to collect data from the air medical industry and develop recommendations for protecting patients from balance billing, improving disclosure and informing consumers of insurance options. We support this process and want it to work so that patients are taken out of the middle and get the care they need.”

ADDITIONAL KEY FACTS ABOUT AIR MEDICAL

• 90% of all emergency air transports are for cardiac, stroke, or other trauma conditions. The remaining 10% encompass specialty pediatric care, burns, neonatal, high-risk obstetrics, neurological, and other conditions.

• 100% of emergency air transports are ordered by an EMT or attending physician based on medical necessity.

• 100% of emergency patients are transported without regard to insurance status or ability to pay.

• 20% of Americans, or 85 million, live in areas where it takes more than one hour to get to Level I or II trauma center.

• More than 70% of patients transported are covered by Medicare, Medicaid, other government insurance, or have no insurance at all. The Government Accountability Office estimates that about 20% of all air medical transports, or 1 in 5, are of patients who have insurance but are transported by an out-of-network air medical provider.

• Medicare drastically under-reimburses for the cost of an emergency air medical transport, covering only 59% of the cost (in 2015 dollars). The average Medicaid reimbursement is even worse, covering only 34% of the cost.

SOAR Statement on Provisions of Lower Health Care Costs Act

“Recently proposed legislation by the U.S. Senate Committee on Health, Education, Labor and Pensions (HELP) would destroy access to life-saving emergency air medical service for millions of Americans, especially those in rural areas.

The Lower Health Care Costs Act includes a provision – Section 105 - that hurts patients, cuts air medical providers out at the knees, removes vital care from rural America—and only benefits health insurance companies. The language would allow insurers to continue paying ever lower rates while continuing to question the emergency medical decisions of doctors and first responders.  It would also leave no recourse against some insurers who refuse to negotiate in-network agreements with air ambulance providers. The unintended consequences of Section 105 will decimate the air medical safety net in rural America so that the cardiac, stroke and trauma patients air medical crew members care for 24 hours a day, 365 days a year, will have no chance to receive definitive care in an adequate amount of time. 

This public policy gives the insurance industry all of the cards and could lead to the elimination of emergency air medical services at a time when large swaths of the country and millions of Americans are losing hospitals and other health care facilities. We urge members of Congress to reject this ill-conceived legislation.”

SOAR Statement on the House Hearing regarding “No More Surprises: Protecting Patients from Surprise Medical Bills”

“The Save Our Air Medical Resources (SOAR) Campaign supports efforts to protect patients from balance bills and ensure access to life-saving emergency air medical care. We urge Congress to get to the root of the problem by fixing Medicare’s chronic under-reimbursement for air medical services, and we call on insurance companies to do right by their patients and consistently cover this emergency service.

“Last year, Congress took a step in the right direction when it directed the U.S. Department of Transportation to collect data from the air medical industry and develop recommendations for improving disclosure, informing consumers of insurance options, and protecting patients from balance billing. We support this work and want it to succeed. Adding a new billing requirement to separate the health care and transportation aspects of an emergency air medical transport would be a step backward, however. Not only is such a separation impossible due to the nature of the service, it would do nothing to protect patients from balance bills or lower costs.  

“We applaud the Subcommittee for taking up this issue and look forward to working with it to preserve access to emergency air medical services and protect patients from balance bills.”

SOAR Statement on the House Hearing regarding “Examining Surprise Billing: Protecting Patients from Financial Pain”

The SOAR Campaign thanks Chairwoman Frederica Wilson (FL-24) and all the members of the Committee for calling today’s hearing to explore strategies on the important issue of surprise billing.  This is a welcome first step toward finding real solutions to take patients out of the middle.

Largely missing from today’s discussion was the role that private insurers play in surprise billing. For example, narrow networks and medical necessity are routine ways in which insurers deny coverage of patient claims in order to increase profits. Recent media coverage has shown that Health Care Services Corporation, which runs Blue Cross Blue Shield plans in five states, spent only 63 percent of premiums on actual medical costs. Insurer Centene was recently fined $1.5 million because their networks provided inadequate access to providers. These practices by private insurers leave patients at risk from surprise bills.

Emergency air medical providers never want to see a patient receive a bill they did not expect or cannot afford. Air ambulances are called by first responders or medical professionals to transport patients to the closest, most appropriate healthcare facility in an emergency. Air ambulances never self-dispatch: they go when they are called, regardless of the patient’s ability to pay or their network status. Yet some private insurers leave patients with large bills because they refuse to negotiate. As a result, air ambulance providers have patient advocates who work with the patient to navigate the insurance appeals process and, in many cases, provide the patient with a discount on their bill. But insurance denials beg the question - if patients can’t rely on private insurance in an emergency, what is insurance for?

To take patients out of the middle, private insurers must negotiate a fair reimbursement to bring air medical providers in-network, which air ambulance providers want to do. This can be accomplished for a small increase in premium as shown by a Montana legislative study which found that for only $1.70 a month more in premium costs, air ambulance services would be covered.  A similar study in Kentucky estimated that the increase would be between $0.92 and $3.69 per person per month.

Beyond that, however, Congress must pass legislation that would require the collection of data from the air medical industry so that Medicare reimbursement rates can be updated to reflect the actual cost of care. Seventy percent of patients flown by air are covered by Medicare, Medicaid or have no insurance, and rates haven’t been updated in almost 20 years. This is unsustainable.

The SOAR Campaign appreciates the Committee’s attention to this issue. Working together on solutions that address the root of the problem will protect patient access to these life-saving services.