WASHINGTON CO. COMMISSIONERS HOLD WORKSHOP ON EMS AIR AMBULANCE BILLING PROCESS

  

Washington County Commissioners learned more on Tuesday about the ins and outs of billing operations with Washington County EMS’ air ambulance service provider, Metro Aviation.

During a workshop, Metro’s Customer Revenue Cycle Support Director, Holly Weber, explained federal laws governing the billing process and how a backlog of claims through Independent Dispute Resolution (IDR) arbitration is causing delays for Washington County to receive payment from insurance providers.

Weber said the No Surprises Act that went into effect in 2022 was created to end surprise medical bills including balance billing, or when a patient is billed for the difference between the amount charged by the provider and the amount approved by the patient’s insurance.  However, the act has been challenged by several lawsuits which, combined with a large amount of claims and only 13 entities set up to perform IDR for all of healthcare, excluding ground transports, has created a logjam.

The IDR process determines what a commercial insurance provider pays to a medical provider should the insurance company refuse to pay a certain amount during a set period of negotiations.  An arbitration board hears the claims of the medical provider and the payer and decides on an amount. 

Weber said with the way the IDR process currently works, it leads to insurance companies initially paying low amounts comparable to Medicare payouts, not wishing to negotiate with medical providers, and choosing to proceed with IDR because the rules tend to favor the payer.  In addition, even if a medical provider wins arbitration, she said there is not much in the way of enforcement to ensure they are paid by the insurance company within the mandated 60-day timeline, contributing to providers—like Washington County—not receiving the full amount they are due for a lengthy period of time.

What works in Washington County’s favor, according to Weber, is that the county is only requesting what is needed to cover costs and is not price gouging, meaning it is looked on favorably in the IDR process.  Commissioner Candice Bullock said that is because the county is a government entity and is not trying to make money off of its constituents. 

Weber said from Metro’s program base specifically, it is averaging about 80-85 percent of the bill charge rate received, meaning the provider usually receives that percentage of what it is charging.  EMS Director Kevin Deramus said that amount is what the EMS department bases its projections on for what is still due to be received.  He said if the department gets that, then it will be “pretty solid.”

Kim Stanley, Chief Compliance Officer at EMS Management & Consultants, Washington County EMS’ billing company, said insurance claims with air transports have a longer lag time than ground transports because more documentation and proof are required in order to show that it was necessary for the patient to be transported by air.  Bullock said there have been rumors that some of the EMS department’s flights were not needed and that this information should dispel them, because an unnecessary flight would not stand to receive any payment through the IDR process.

According to Stanley, the county has 22 air ambulance flights pending compensation from commercial insurance.  Ten are in open negotiations, while 12 are submitted for IDR.  If all IDR timelines are followed, final payments would be made within 83 days of the start of the IDR, which is 143 days from the initial disputed payment.

Stanley said proposed federal budget talks would extend the No Surprises Act and its processes to ground ambulance transports in 2025.  If there are not new federal rules, she expects Texas will take up similar balance billing provisions.  She pointed to one piece of legislation, Senate Bill 2476, which would prohibit municipalities from engaging in balance billing.  She said the bill has the support of the Texas EMS Alliance and could be beneficial for Washington County because it already does not engage in balance billing.

Commissioner Kirk Hanath said if new legislation is passed on that front, it will not affect Washington County in the way it would impact others, adding he feels the county was “so far ahead of the curve.”