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Paying For an ER on Wheels

New Ambulance Billing Policy Aims to Make Process Compassionate, Officials Say

By Timothy Dwyer
Washington Post Staff Writer
Thursday, February 24, 2005; Page VA18

Lt. Natalie Robb, dressed in her fire department shorts and T-shirt, was getting ready for an afternoon workout at Station 32 on Burke Centre Parkway. The elliptical machine, treadmill and a weight-lifting station were on a little platform built by firefighters and located right behind the spot in the garage where Medic Unit 432 was parked.

The cab doors of the medic unit were open, as usual, ready for quick access. Paramedic Robb opened the door to the large, box-shaped rear compartment and stepped in, ready to give a little tour.

Ambulance Outside Inova Fairfax Hospital
Ambulance Outside Inova Fairfax Hospital
Starting April 1, Fairfax County will charge $300, $400 or $550 for each ambulance trip to the hospital, depending on the severity of the illness or injury. In addition, the county will assess patients $7.50 a mile for each trip. (James M Thresher - The Washington Post)

Fee System Particulars
From washingtonpost.com at 12:00 AM

When will Fairfax County start charging for ambulance trips?

Friday, April 1.

Who approved the fee?

After public hearings, the county Board of Supervisors on May 24 approved Section 4-26-1 of the county code establishing a fee schedule for emergency medical service transports provided by county vehicles. In addition, Section 32.1-111.14 of the state code authorizes counties to make "reasonable" charges for the use of emergency medical service vehicles.

How do I call an ambulance?

Call 911.

What are the charges?

Fees are $7.50 a mile from the pickup point to the hospital. On top of that, these charges apply:

• $300 for a basic transport.

• $400 for advanced life support, or Level 1 transport -- a serious medical problem or traumatic injury.

• $550 for advanced life support, or Level 2 transport -- a cardiac arrest.

If I don't have health insurance and cannot pay my bill, what options do I have?

Patients transported who do not have health insurance will be sent a request for information that will include a financial hardship waiver form, according to the Fire and Rescue Department. No one will be denied service because of inability to pay or lack of insurance.

How does billing work?

Fairfax County has contracted with a company to handle the billing. After patient care is provided, insurance information will be obtained routinely, most often at the hospital. The county will waive co-payments and deductibles for county residents. Residents may receive an initial statement from the billing company. For county residents who are uninsured, Fairfax has adopted a compassionate billing policy.

What if my insurance company will not cover my ambulance bill?

The county's billing service will attempt to gain all information required to show the medical necessity of the transport. However, if the claim is ultimately rejected, the Fire and Rescue Department will consider the charge uncollectable for county residents.

Whom do I call if I have a billing or insurance problem?

The billing company will have customer service representatives to address those questions. If you are not satisfied with their answers, call the Fire and Rescue Department's patient advocate at 703-246-2266.

Will Medicare pay for ambulance trips?

Medicare will pay 80 percent of the charge for medically necessary transports. Remaining co-payments or deductibles will be waived for county residents.

If the co-payment for the ambulance trip is being waived, will there be any out-of-pocket expenses?

There will be no additional charges for ambulance transport for county residents who have health insurance, Medicare or Medicaid. Patients who live outside the county will be billed for charges not covered by insurance.

If you have questions or would like to schedule a community presentation about the billing program by a fire and rescue official, send an e-mail to EMSTransportBilling@fairfaxcounty.govor call 703-246-2266. More information is at www.fairfaxcounty.gov/fire.

SOURCE: Fairfax County Fire and Rescue Department

A stretcher took up the center of the compartment. On one side was oxygen equipment, a heart monitor and a defibrillator. A radio and cell phone were near the head of the stretcher. Supplies, including drugs and intravenous equipment, filled the drawers.

This is Robb's work space. It is a miniature model of a modern hospital emergency room. But it's on the chassis of a heavy-duty truck. "We do a lot of things they can do in the ER, to a point. We have our [rules and procedures] that limit us," Robb said, "It's a nice little office, it really is."

Starting April 1, Fairfax County will impose a fee for rides in Robb's "office." The county government will charge $300, $400 or $550 for each ambulance trip to the hospital, depending on the severity of the illness or injury. In addition, the county will assess patients $7.50 a mile for each trip.

County fire and rescue officials say they are trying to create a compassionate way for people to pay their bills.

"The way we have been able to set up this process, it is going to be transparent to the patient when the patient is most in need," said Fire and Rescue Department Chief Michael P. Neuhard. "Our system is designed to help people, and nothing is going to change that. There is nothing about billing in the front end of the process."

The county has hired a company to handle billing. Based on information gathered at the hospital, patients' insurance companies will be sent a statement for the emergency medical transportation services.

No co-payment will be charged, except for patients who don't live in Fairfax. For older residents, Medicare or Medicaid will be billed directly.

Patients with no insurance coverage will be sent a "request for information" that will include a waiver form. The county will waive transportation charges for needy patients and will not use agencies to collect unpaid fees. After three waiver notices are sent out, the fees will be considered uncollectable.

The billing policy was carefully crafted as a response to years of often emotional debate about ambulance fees. Some were dead set against them because people feared the fees would hit the poor and low-income elderly the hardest. Others rejected the idea of fees simply because they felt that one of the richest counties in the nation could afford to provide its citizens with free emergency medical transportation.

Supervisor Penelope A. Gross (D-Mason) has been a longtime opponent; she made the motion to remove an ambulance fee proposal from the county budget two years ago. "I was convinced that it had not been properly vetted," said Gross. "I wanted to have a little bit more study into how it was going to impact uninsured people and elderly folks, how this was going to impact on my constituents."

After a task force studied the issue and brought it back to the Board of Supervisors last year with suggestions on how to make the fee fair to low-income and uninsured residents, Gross changed her mind, and the supervisors approved the proposal to begin charging for rides this spring, following a public education campaign.

"There did not seem to be the kind of overwhelming negative impact that I thought, and so I was able to support it in the [fiscal 2005] budget," she said.

The county mailed brochures to Fairfax residents last month explaining the ambulance fees. In the brochure as well as during interviews, the fire chief and other county officials stressed that people should not stop calling 911 because they are afraid they cannot afford the service.

"I think the important thing that people need to know," said Gross -- "and we need to reinforce this all the time -- is that the billing procedure will take place after the transportation and not before. So people need to feel comfortable calling 911 for assistance, and no one will ask to take their credit card or for proof of payment.

"And if this ever does happen," Gross warned, "I want to be the first one to be contacted."

Gross said many county residents may have health care plans that include coverage of ambulance fees. "Most of us are paying for ambulance service through our insurance companies," said Gross. "The insurance companies were making a profit, pocketing that part of our premium."

Neuhard said the county expects to generate about $6 million from fees in the first full year of operation, an estimate that he said is based on recovering the fee at least half of the time.

"We may do better than that, but during the first year of operation, there are some things we might have to work through," the chief said.

Revenue generated by the fees will go into the county's general fund and not to the Fire and Rescue Department, which has a budget of about $130 million, Neuhard said.

Last year the fire department went on 91,000 calls, according to spokesman Dan Schmidt, and about 75 percent of those were for emergency services. The department transported nearly 50,000 patients to hospitals last year, according to department records.

Over the last 30 years, the primary task of fire departments around the country has evolved from putting out fires to saving lives. Every piece of equipment the Fairfax County Fire and Rescue Department owns, whether ladder trucks, engines or medic units, is staffed with at least one emergency medical technician.

"In Fairfax County, we have a very dedicated and progressive fire and rescue service," Neuhard said. "We worked hard to get there, and it is harder sometimes to maintain those [service] levels over time. We are still a growing county, still a growing department. We are adding one new station in the next year, one the year after and one the year after that."

Fairfax County will become the latest jurisdiction in the region to charge ambulance fees. The District, Arlington County and the City of Alexandria currently charge for emergency medical transportation.

In Fairfax, the fire department operates a hybrid system of full-time and volunteer personnel. The county has 35 stations and 1,226 uniformed personnel. In addition, there are 12 active volunteer fire departments in the county and some 300 volunteer firefighters available to the county for additional staffing. Volunteer ambulance crews back up and supplement county crews.

The volunteer firefighters were against charging ambulance fees in part because they said the county could afford the service.

"That was the position taken by the volunteer system; we were opposed to the fees," said Mark Servello, 45, of Chantilly, who has been a volunteer firefighter for six years and runs a computer consulting business. While Servello said he was against the plan, now that it is moving forward he is working as part of a task force to make sure the billing process goes smoothly.

"If I were to go into a rural area where the fees are necessary to provide the service, it's not a problem," Servello said. "And around here there are a lot of rural areas that do bill. . . . I think the tax base in Fairfax County, which has one of the highest median incomes in the nation, should provide for that service, and we should not be billing people an additional fee."

Servello said he understood the supervisors' motivation in implementing a fee schedule as a way to reduce reliance on the property tax to pay for such services. He said he would be more supportive of the fees if the revenue were going directly to the fire department instead of into the county's general fund.

The department has begun training classes for firefighters on the fee plan. In addition, Neuhard has been attending many community meetings, talking with various ethnic and senior citizen groups among others, to explain firsthand to county residents how the system is going to work. In the next few months, the county also plans to run television spots to explain the system, he said.

Robb, the paramedic, said once the plan begins, it will be the people riding the engines and medic units who will get direct exposure to how people feel about it. But it will not affect how she does her job, Robb said.

"There will be no impact at all," she said. "Patients can ask questions, and we are willing to explain to them what billing is all about, but it is something that won't impact us. We are going to take the same information we always took. We're going to take them to the same hospital and give them the same treatment we always have. Nothing is going to change in that department."


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