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Leanne Grover, EBS in Barron County, helped a client successfully appeal a denial for air ambulance services. The man was vacationing in New Mexico when he had a medical emergency that required specialized surgical care. He was flown from a small local hospital to a larger facility in downtown Albuquerque. Medicare denied coverage for the air ambulance because he had not been taken to the nearest alternative hospital. Leanne was able to get letters from each of two closer hospitals stating that they would not have been able to provide the level of care the patient needed. The claim was approved at the redetermination level to cover air ambulance costs exceeding $99,000!
Monetary Impact = $99,000
11/30/2022
Story #42
Mindy helped a client who was dealing with some ambulance billing issues. The client had received ambulance bills from three separate dates of service. However, the ambulance provider had not bothered to bill her Advantage plan for two of those dates. The one claim that had been submitted was submitted late, and the explanation of benefits clearly said that, because of the late submission, the client was not responsible for the bill. With Mindy's help, a demand bill letter was sent to the ambulance provider asking them to submit the remaining claims and reminding them that, as a Medicare-enrolled provider, federal law required them to file claims for services provided to Medicare beneficiaries. The ambulance provider submitted the remaining two claims to the Advantage plan, and the services were covered. In addition, the provider agreed to stop billing the client for the claim that was submitted late. This saved the client over $3,000!
Monetary Impact = $3,000
9/30/2022
Story #28
Eau Claire County EBS Jessica Smith persisted in assisting a woman with her ambulance appeal until they received a successful decision. The woman had a medical history of chronic heart failure, severe aortic stenosis, a heart murmur, and kidney failure. On the day of service, she was experiencing left-sided chest pain, back pain, and believed she was having a heart attack. Her husband called 911 so that an ambulance could take her to the hospital as soon as possible. Sadly, her adult son had just passed away two weeks prior due to heart disease, which was very prevalent in her family history. The ambulance company had correctly billed the claim as “advance life support—emergency transport" due to the fact that she was given a 12-point ECG during the ambulance ride which indicated tachycardia. However, the ambulance company also submitted the claim to Medicare with a “GY" code at the end meaning “statutorily not covered by Medicare." Due to the “GY" code, Medicare denied payment for the claim. Jessica collected the Medicare Summary Notice, the ambulance run report, and medical records as evidence. She then helped the couple to appeal to Medicare twice only to receive denials by both NGS and also C2C Solutions. However, Jessica knew that this claim should have been covered by Medicare because there is a presumption of Medicare coverage for ambulance rides when the person can only be moved by stretcher (which was the case here), and when the patient exhibited signs and symptoms of acute cardiac distress or chest pain. Jessica helped the client to request an Administrative Law Judge (ALJ) hearing. Prior to a hearing being scheduled, the ALJ issued an on-the-record decision, meaning that he had reviewed the file and exhibits that had been submitted and felt that a hearing did not need to be held because he already had sufficient information to make a favorable decision. After a year and a half of appealing, Jessica and the client finally received a fully favorable decision.
6/30/2022
Story #18