Glasgow Daily Times, Glasgow, KY

November 13, 2013

Humana will remain out of network for ambulance runs

By MELINDA J. OVERSTREET
Glasgow Daily Times

GLASGOW — The local ambulance service will continue to not have a contract to be an in-network provider with Humana insurance company, and its board of directors plans to discontinue its contract with Anthem/Blue Cross-Blue Shield.

The Barren-Metcalfe County Emergency Medical Service board called a special meeting to discuss that issue and one other, scheduling it for a time that representatives of Medical Accounts Receivable Services, which contracts to handle the ambulance service’s billing, could be there to answer questions about the issue.

Chasity Oakes, who has Humana health insurance, came to the October board meeting to express her dissatisfaction over being billed at an out-of-network rate for a medically recommended ambulance trip to Louisville for her son.

She said the difference cost her about $400, and she wanted to know why the ambulance service would not be a network provider, or at least bill as such, as it’s the only local such service here.

By the time the October meeting occurred, she believed it had gotten worked out that she would be billed at the in-network rate.

As a result of the discussion, the board wanted more details on why MARS had recommended against having a contract with Humana and decided to set up the extra meeting.

Bill Harrod, chief executive officer for MARS, explained Wednesday that in Kentucky, ambulance service claims are virtually always processed at the in-network coverage rate even when they don’t have a “network” contract, with the only exception being privately owned services. Ambulance services have to obtain a certificate of need from the state, and that CON process essentially limits the number of services that can operate in any particular area, Harrod said.

It also means the service provider cannot pick and choose who their patients are.

Harrod said it’s common for an insured person to call and speak with an insurance customer service representative and be told one thing and call right back and be told something entirely different by another representative, regardless of the insurance company, and seems to be what happened in Oakes’ case, further adding to the confusion.

But when MARS heard about her case, “it raised a red flag,” he said, so the company pulled other Humana cases and found that they generally were paid at in-network rate, and the only differences in the cases depended on their specific policy and the deductibles and such.

Harrod said that when service provider contracts with an insurance company, the provider has to accept the private insurance company’s reimbursement rate and write off the rest; it cannot bill the insured for the difference. Out-of-network providers get a higher reimbursement rate, generally, and can bill the insured.

Edmonton mayor and board chairman Howard Garrett asked why, then, the ambulance service had a contract with Blue Cross-Blue Shield, and Harrod said that had been done before the service contracted with MARS.

Nancy Jolly, office manager at the ambulance service, said it was participating with all private insurers before the MARS contract, but when MARS came on board, the billing company’s recommendation was to only participate with BC-BS, so the other contracts were dissolved. She said she believed the  contract with Blue Cross automatically renews until either party cancels it.

Board member and Metcalfe County Judge-Executive Greg Wilson asked what the “pros” were for getting out of the contracts.

Because there is no other service to act as competition,  the insurance companies process it as in-network, regardless, Harrod said.

Board member Melanie Watson, compliance officer at T.J. Samson Community Hospital, which partially owns the ambulance service, said there is no reason to have a contract when BMCEMS is the “the only game in town,” so there is no network.

Harrod confirmed that he still recommends no contract with Humana and suggested they review the Blue Cross contract.

He told the board that in a few states, if a provider does not have a contract with them, Blue Cross “will stick it to you by sending the check to the patient,” instead of the provider, lowering the chance the provider will actually get paid. One state, Mississippi, just recently passed a law to keep insurance companies from doing that, Harrod said.

For MARS’ billings, that meant payments increased $10,000 to $18,000 a month in Mississippi, he said.

“So they won’t send it to the patient in Kentucky?” Wilson asked.

Harrod said that was correct, but they could try to change that in the future.

Watson said sometimes the added amount a provider could bill isn’t worth the trouble it takes to collect it from an individual, depending on the amount.

EMS director Mike Swift said he believed at some point the reason the service had a contract with Blue Cross was related to their sending the checks to patients, and Wilson said he thought it would be better to address that issue as it arises or talk with legislators and ask them to pass a law similar to Mississippi’s.

“I think it’s worth the risk to get out,” said Freddie Norris, board member and Glasgow city councilman, and he put it in the form of a motion, which passed unanimously.

The other issue on the agenda was whether the ambulance service should provide a discount to T.J. Samson hospital’s hospice program as requested.

Swift said he had spoken with a representative from the hospice, but no specific dollar or percentage amount was named.

“They haven’t put anything in writing?” Garrett asked, and Swift said they had not.

After a brief conversation regarding how billing is different for hospices because they are billed directly rather than the patient or patient’s insurance, Norris suggested putting off any vote on the matter until more information could be obtained.

Rhonda Riherd Trautman, board member and Glasgow mayor, put the idea of tabling the issue into the form of a motion and the board unanimously agreed.

Garrett asked Swift to get numbers together on the impact such a decision could have.

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