Concord Monitor – NH ambulance service faces problems from big surprise patient bills to struggling companies
Concord Monitor – NH ambulance service faces problems from big surprise patient bills to struggling companies

The ambulance service may be one of the most basic and important parts of the health care system, but it’s also a financial mess in New Hampshire, for both patients and private companies.

“We’ve talked to users who say, ‘I got home and obviously I need to be seen in the emergency room, but I was sitting there thinking, ‘Can I wait to try to get a family member to take me to the hospital?’ said DJ Bettencourt, commissioner of the New Hampshire Department of Insurance. “Someone who needs emergency transportation to a hospital shouldn’t have to think about whether their particular health coverage is in network with this (ambulance company).”

A famous example occurred in February when a hiker suffering from hypothermia and frostbite was carried off Mount Washington in extreme winter weather after an 11-hour rescue, only to drive himself to the hospital because he was afraid of how much an ambulance ride would cost .

At the same time, Bettencourt said, “We started seeing reports this summer that private ambulance providers are experiencing significant financial difficulties … particularly in rural areas of the state.”

One problem is that about 80 percent of transportation covers people on Medicare or Medicaid, “who don’t pay anywhere” the cost, Bettencourt said. This is especially true in rural areas, where scattered populations make it very expensive for a private, for-profit company to maintain 24/7 coverage.

Municipal services that are part of the budgets of fire departments or other emergency services see less immediate financial hardship, but face many of the general headwinds, he said.

Issues like these are not unique to New Hampshire and have led lawmakers in Washington and Concord to consider various changes to billing, network assignments and reimbursement rates, including some bills making their way through the state House. They also had the state insurance department hold an “ambulance summit” that resulted in a lengthy report issued Friday containing a number of recommendations for lawmakers to consider.

“It’s a perfect opportunity to talk about an issue that’s been around for … two decades,” Bettencourt said.

One thing that’s clear, he said: “We’re going to need higher (recovery) rates (from insurers), especially in rural and super-rural areas of the state.”

The report makes several recommendations.

One is to ban “balance billing,” where patients must pay the difference between the cost of the ambulance and the amount the insurance company will cover. The difference can be hundreds or even thousands of dollars if the patient’s health insurance does not consider the ambulance company part of the network.

This is a particular problem, said Deputy Insurance Commissioner Keith Nyhan, because especially in rural areas there is often only one ambulance available.

“Especially in an emergency situation, consumers do not have the option of choosing whether the ambulance company is in-network or out-of-network. They just show up,” Nyhan said.

Consumers concerned about an account balance can call the Insurance Division’s Consumer Services Hotline at 800-852-3416 or email [email protected] for assistance.

Also, the report recommends direct payment, a strong desire for ambulance providers.

The problem, Bettencourt said, is that when insurance companies cut a check to reimburse the ambulance provider, they send it to the patient who owns the policy and expect the patient to pay the ambulance.

“In many cases, the consumer isn’t sure why they got that check and runs away with it.” They think, ‘Oh, this must be a reimbursement’ … so it never gets to the provider,” he said.

Both proposals are included in separate bills moving through the legislature.

The recommendation says the changes should be part of overall changes to the system, which include better data collection from all providers, private and public, and better monitoring of service costs and availability.

Congress is also considering legislation to cap balance billing for ground ambulances, though it’s unclear when or if that will become a reality.

The full report can be found on the New Hampshire Division of Insurance website at

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