By Alison
Kodjak, NPR News SEPTEMBER 26, 2018
It was
the first — and only — time Dr. Naveed Khan, a 35-year-old radiologist, ever
rode in an all-terrain vehicle.
Khan
took the wheel from his friend and drove circles in the sand, on a trail along
the Red River in Texas.
“As
soon as I turned to the side where my body weight was, this two-seater vehicle
… just tilted toward the side and toppled,” Khan recalled. It landed on his
left arm.
“I had
about a 6-inch-wide exposed flesh gap that I could see below, on my forearm,”
he said. “And I could see muscle. I could see the fat. I could see the skin.
The blood was pooling around it.”
Khan,
feeling lightheaded, tied his jacket around his arm like a tourniquet. He and
his friend managed to right the ATV, drive back toward the street and call 911.
When an
ambulance delivered him to the emergency room at United
Regional Health Care System in Wichita Falls, Khan was
surprised to hear a doctor murmur that it was the worst arm injury he’d ever
seen.
Khan
needed immediate helicopter transport
to a trauma center for surgery in Fort Worth, if there was any hope of saving
the arm.
Groggy
from painkillers, Khan managed to ask the doctors how much the flight would
cost and whether it would be covered by his insurer. “I think they told my
friend, ‘He needs to stop asking questions. He needs to get on that helicopter.
He doesn’t realize how serious this injury is,'” Khan recalled.
Flown
108 miles to John Peter Smith Hospital in
Fort Worth, the closest Level I trauma center, Khan was whisked into surgery to
clean out the wound, repair his shattered bones and get blood flowing to the
tissue.
He had
a total of eight operations to try to save his left forearm before he finally
gave up. After weeks in the hospital, he asked the doctors to amputate, so he
could get on with his life.
And
then the bill came.
Patient: Naveed
Khan, 35, a radiologist and married father of three small children in
Southlake, Texas.
Total
bill: $56,603 for an air ambulance flight. Blue Cross Blue
Shield of Texas, Khan’s insurer, paid $11,972, after initially refusing
altogether; the medevac company billed Khan for the remaining $44,631.
Service
provider: Air Evac Lifeteam, an air ambulance company that operates
130 bases in 15 states. It’s owned by Air Medical Group Holdings, a holding company that owns
four other air ambulance companies and one ground ambulance company. Air
Medical, in turn, is owned by the giant private equity firm Kohlberg Kravis Roberts, or KKR.
Medical
service: Khan was flown from the United Regional Health Care System
in Wichita Falls, Texas, to the John Peter Smith Hospital in Fort Worth.
What
gives: Khan got his first call from Air Evac Lifeteam just
three days after the accident, while he was still lying in the hospital. A
company representative told him the helicopter ride would likely cost more than
$50,000 and asked him how he planned to pay.
For
Khan, rapid transportation to the trauma center was absolutely essential since
the blood supply to his arm had been cut off, said Dr. Raj Gandhi, the
medical director for trauma services at JPS Hospital.
“If
there’s no blood going that means there’s no oxygen,” he said. “It there’s no
oxygen, that means those cells are going to die.” Minutes are precious and the
helicopter can get from Wichita Falls to Fort Worth in an hour or less, half
the time it takes by ground ambulance, he said.
But
complaints about sky-high bills to patients for air ambulance services are
common. Since launching the “Bill of the Month” series in February, NPR and
Kaiser Health News have received more than a dozen bills from critically ill
patients like Khan who were charged tens of thousands of dollars for an air
ambulance ride even after insurers’ payments.
Air
ambulance companies defend their charges.
Rick Sherlock, president of the Association
of Air Medical Services, a trade group, said air ambulances require
a more highly trained crew than a ground ambulance, because only the sickest or
most seriously injured patients need air transport.
AAMS commissioned a study to
determine the actual cost of a medevac ride. The report found it takes about
$2.9 million a year to run a single helicopter base. Each base handles about
300 transports a year, and the rides cost about $11,000 each, according to the
report.
A
spokeswoman for Air Evac Lifeteam said the company bills people so much because
it is trying to make up for what she said are meager payments from Medicare and
Medicaid.
“Our
real cost per flight is the $10,200 plus the unreimbursed cost on each flight
for Medicare, Medicaid and patients without any coverage,” wrote Shelly
Schneider, the company spokeswoman.
The
Centers for Medicare & Medicaid Services said it pays an average of $4,624
per ride, plus $31.67 a mile — which works out to an average Medicare
reimbursement of $6,556 for helicopter ambulance rides for seniors. Medicaid in
most states pays less.
The
industry has been advocating hard to get Medicare to boost its reimbursements,
Sherlock said. Legislation pending in
both the House and Senate would do so, but there hasn’t been much movement on
those bills.
Others
say the industry’s cost estimates are inflated by profit-driven expansion of a
lucrative industry. Ground ambulances often carry critically ill patients, too.
Too
many air ambulances sit idle much of the time, said Dr. Ira Blumen, a professor of emergency
medicine at the University of Chicago and medical director of the university’s
Aeromedical Network.
Blumen
said the industry — which is dominated by a few companies owned by private
equity firms — expanded dramatically the last time Medicare boosted its
payments, in 2002. And now there are too many helicopters — 908 as of last
year — fighting for patients and profits at the same time.
“The
number of helicopters is outrageous for the continental United States,” he
said. In the 1990s, most helicopters ran more than 500 flights per year on
average. At that rate, the cost per flight today would be less than $6,000.
A BCBS
of Texas spokesman said the insurer does have a contracted rate with an
in-network air ambulance company, but it is not Air Evac Lifeteam. After
initially refusing to pay anything for an out-of-network claim, it agreed to
the $11,972 payment.
But in
some sense, the reason ambulance companies charge so much is simply because
they can: Air ambulances are largely regulated not as health care but as part
of the aviation industry. Federal laws prevent states from limiting aviation
rates, routes and services.
So many
people have been hit with shockingly high air ambulance bills that members of
Congress on both sides of the aisle are trying to do something about it.
Legislation to reauthorize funding for the Federal Aviation Administration that
is moving through Congress now would set up a council of industry experts to
address balance billing and other issues, and set up a complaint line for
consumers.
Resolution: Khan
has allowed Air Evac Lifeteam to negotiate with BCBS of Texas over the
remaining $44,000 air ambulance bill. The company has asked him to appeal to
the state’s Department of Insurance, and though he first balked at the suggestion,
he’s now considering doing so. Khan says he doesn’t understand why the
helicopter flight, an integral part of the emergency medical care he received,
is treated differently than his surgeries, nursing care and physical therapy.
“I
thought that this was another piece of that puzzle,” he said. “It turns out
that this was glaringly different.”
He is
waiting for resolution as he gets accustomed to life with his disability.
Holding his baby son, he asked in frustration: “How do I hold him while he’s crying
and at the same time heat up his bottle?”
Khan,
who has had to fight with his insurance company to get coverage for a
prosthetic arm, is frustrated to learn that the air ambulance company expects
him to pay far more than the actual cost of his flight.
“It’s
unfair,” he said. “It’s random, it’s arbitrary. It’s whatever price they want
to set. And to put that onto a person who’s already been through what I’ve been
through, I hate to say it, but it’s cruel.”
The
Takeaway: Most people with health problems serious enough to require a
helicopter flight are in no position to ask if the medevac company is
in-network or whether there’s a choice. But if you or a family member has time
to ask, it could pay off.
Steps
you should take if you’re faced with a huge bill for a medevac ride:
·
First, let your insurer’s process play out. Blue Cross Blue
Shield of Texas first denied Khan’s claim altogether. But he looked closely at
his policy and saw that the threat of loss of limb was explicitly covered. He
appealed, and that’s when the insurer paid $11,972.
·
Second, negotiate! The air ambulance company might be willing to
negotiate a settlement for a fraction of the bill to avoid turning to debt
collectors, who would pay them pennies on the dollar.
Both
Sherlock of the Association of Air Medical Services and Schneider of Air Evac
Lifeteam said companies will try to determine what a patient can afford. So
people with high incomes may find it hard to obtain a substantial reduction for
their bill. Still, if patients know the true cost of the service they received,
they may be better equipped to negotiate a discount.
Many
air ambulance companies offer membership plans that can cost less than $100 a
year, and guarantee that the company will accept whatever payment an insurance
company makes without billing the patient for the rest. But buyer, beware: When
someone needs an air ambulance, they are often not in a position to choose
which company will respond to the call.
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