Ambulance coverage is an important part of Medicare insurance and beneficiaries frequently have questions about when ambulance transportation is covered.
There are three guidelines Medicare looks for: medical necessity of the ambulance ride (could the person have been transported safely by another means?); if any medical treatment was provided while in the ambulance (were medications given, administration of oxygen, or EKG); and what diagnosis codes the provider used to bill Medicare for the ambulance transportation.
Regardless of insurance coverage, it is important to call an ambulance if there is a medical emergency.
Some reasons to call an ambulance (this is not an all-inclusive list):
•Need for skilled medical treatment during transport (need vital signs monitored or administration of oxygen)
•May have injured spine, need mobilization
•Possible heart attack or stroke
•Injury or fall with possible broken bones, need mobilization
Be aware that Medicare only covers transportation to the nearest facility that provides the care needed. If a person chooses to go to a facility farther away, the beneficiary will be responsible for any additional mileage costs. Medicare does not consider hospital preference, network restrictions, or doctor preference in determining the closest facility.
Medicare also covers air ambulance transport when medically necessary. Air ambulance transport may be appropriate if a person is in a remote area that a ground ambulance could not reach, if it would take too long for a ground ambulance team to respond, or if the local hospital cannot provide the care needed and the nearest alternative facility is too far away.
Some examples of when Medicare would cover air ambulance transportation:
•Intracranial bleeding– neurological intervention
•Burns requiring treatment in burn center
•Condition requiring treatments in hyperbaric oxygen unit
•Multiple severe injuries
When the ambulance provider is billing Medicare, it has to make a subjective analysis of whether there was a medical emergency. Sometimes the ambulance provider is not aware of all the facts, does not know a patient’s related medical history, or misjudges a situation. This could result in a denial of coverage by Medicare for the ambulance ride.
A benefit specialist may be able to assist if Medicare has denied coverage of an ambulance ride.
It is important to provide the entire Medicare Summary Notice or Evidence of Benefits statement so that he/she can best understand the reason for the denial.
A benefit specialist will also help obtain medical records and the ambulance trip report to demonstrate the medically necessary and emergent circumstances.
The benefit specialist can summarize medical issues and submit a Medicare coverage appeal to be decided by a neutral third party agency. Appeals must be submitted within certain timeframes.
For questions or information for Jefferson County residents age 60 or over, contact the elder benefit specialist at the Aging and Disability Resource Center by calling (920) 674-8734.