Agreements Halt Improper Billings for Ambulance Service

June 14, 2004

New York Attorney General Eliot Spitzer announced two separate agreements that will help reform billing practices for ambulance services and provide restitution to consumers who were overcharged.

In the first agreement, Vineall Ambulance Co., based in Oneida County, has agreed to reimburse consumers for improperly billing them for the difference between the amount Vineall charges and the amount the consumer’s health plan paid.

In the second agreement, WellCare of New York, a Medicare HMO, has agreed to contact some 5,000 people who used ambulance services between 1998 and 2002 and provide refunds to those who may have been required to pay a portion of a bill for services that was supposed to be covered in full by the health plan.

The agreements follow a lengthy investigation by Spitzer’s office of ambulance service in rural and other areas of the state.

“My office has received numerous complaints from consumers, especially those who live in rural areas, who have been billed improperly for ambulance services,” Spitzer said. “These so-called balance billing practices are wrong, and our action in these cases sends a strong message that we will enforce state and federal law that protects consumers who use this essential emergency service.”

The Vineall case began when the Attorney General’s Health Care Bureau received a complaint from a consumer who received a bill from the company even though his health plan had already paid for the ambulance services. An investigation revealed that Vineall reportedly had a policy of billing consumers with health insurance for the balance between Vineall’s charges and the health plan’s reimbursement rate. Such “balance billing” is prohibited under New York’s “Ambulance Mandate,” which went into effect on Jan. 1, 2002.

The WellCare case began when the Health Care Bureau reportedly received a complaint from a consumer who was billed by an ambulance company for services. The consumer maintained that WellCare was supposed to cover such services in full. An investigation revealed that WellCare was indeed supposed to cover the full cost (except for co-payments and deductibles) of ambulance service by participating ambulance companies. However, the HMO did not have any participating ambulance providers in the entire Hudson Valley region.

WellCare’s subsequent failure to pay the full charges for the non-participating ambulance provider violated federal regulations and state law forbidding deceptive business practices. Since April 2002, federal law, in a provision similar to New York’s Ambulance Mandate, requires Medicare HMOs to pay, and non-participating ambulance providers to accept, Medicare’s approved reimbursement amount for ambulance services as payment in full and prohibits billing consumers for the balance between that amount and the providers charges.

Vineall, which serves customers in the Utica-Rome area, has already identified several consumers who were improperly billed and has begun making restitution to them. Consumers who believe they were improperly billed by Vineall and have not received a refund can submit complaints to the company for a period of 90 days. Vineall has also paid $2,000 in penalties and costs.

WellCare will send over 5,000 letters to its Medicare enrollees who used ambulance services from Jan. 1, 1998 to March 31, 2002 to determine which consumers paid for ambulance charges that WellCare should have covered in full. The company will make restitution to those consumers, who are believed to live mainly in the mid-Hudson region. In addition, WellCare has also agreed to pay $60,000 in penalties and costs.

Spitzer commended both Vineall and WellCare, which is now under new management, for cooperating with his office to promptly resolve these matters.

An investigation of ambulance service balance billing and reimbursement practices across the state is continuing.

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