Being an emergency medical service provider in a rural, lower-income population certainly has its challenges, says Dane Sprague, president of Le Roy Ambulance Service, Inc. Board of Directors.
A good percentage of folks using the ambulance service are on Medicaid or Medicare and/or request not to be taken to a hospital, which either cannot be billed or reimbursed.
“I find a good portion of what we do goes unreimbursed in terms of Le Roy Ambulance Service. We go out on a call, and we may provide treatment to an individual that doesn't involve transportation. And we get no reimbursement from the government programs for Medicare or Medicaid for that type of treatment. And if it's a Medicaid patient, we can't even bill them for that,” Sprague said Wednesday to The Batavian. “I haven't seen the specifics of the legislation or what type of rate structure they're proposing, but anything at this point would be beneficial because, as I said, we provide so much unreimbursed care.
“In a typical month, this past month of August, I think we had 125 calls that we went out on. Only 87 of those were actually billable,” he said. “We’re providing a lot of unreimbursed care to people. If they don’t pay us we still can’t refuse service. If somebody needs care they’re going to get care regardless of their insurance status or how much they may owe us for past visits or whatever. If they’re a Medicaid patient, there’s no provision for that.”
He is hopeful that Gov. Kathy Hochul will sign a bill endorsed by the state Association of Counties this week that would allow EMS agencies and ambulance networks to be reimbursed for treating patients at the scene of the incident and/or transporting them to non-emergency room care facilities for treatment and triage.
The legislation has been in the works, and the association adopted a resolution during its annual fall meeting this week. Here is the full resolution awating Hochul's signature. The legislation is now on Hochul’s desk for approval. It is considered critical to ensure that EMS providers, including Le Roy Ambulance Service and Mercy EMS, two providers under contract for Genesee County, are financially stable and can properly operate and serve residents of New York State.
The EMS legislation only covers Medicaid Insurance, which has not been reimbursing providers, county Manager Matt Landers said, and does not cover Medicare or private insurance.
“I support this resolution as it compensates emergency responders for sevices provided and helps shore up the finances of our resource-strapped first responder agencies,” Landers said. “The current model of only reimbursing for transports to a hospital ignore the many instances where a patient receives costly treatment at the scene or when the ambulance transports the patient to a more ideal location for the specific situation, such as an urgent care facility or a mental health treatment facility.”
Genesee County has seen a gradual increase in the need for Medicaid, a joint federal and state program that provides health coverage for people with limited income and resources. It has grown from 13.3% a decade ago to about 20 percent in 2022, according to datausa.
About 70 percent of Le Roy Ambulance Service’s patients are covered by government programs such as Medicaid, Sprague said. And as a result, “we’re operating at a deficit because of poor reimbursement,” he said.
“A good portion of what we do goes unreimbursed. If we provide treatment to an individual but provide no transportation to a hospital, we receive no reimbursement. We cannot even bill them for that,” he said. “Anything at this point would be beneficial.”
“(Insurance/Medicare) only pay because of a transport to the hospital,” he said. “Anything that will enhance our ability … would be great. Hopefully Kathy Hochul will sign it.”
Under current law, EMS agencies are only reimbursed when transporting a patient to a hospital emergency room. This arrangement is not only financially challenging for EMS agencies, but it also contributes to patients being transported to healthcare settings when a hospital emergency room may not be the most appropriate setting to administer treatment.
Additionally, hospital emergency rooms across the state are already beyond capacity, county officials said, with extraordinary wait times for admission to a hospital bed and is often the most expensive care setting possible for the patient.
It’s not like there haven’t been exceptions in the past. During the COVID pandemic, the Centers for Medicare and Medicaid Services (CMS) allowed waivers for ambulance services to be reimbursed for treatment in place and transportation to an alternative provider, but those ended in May 2023. Data from these waivers indicates that reimbursing EMS for treatment in place and transportation to an alternate provider would save the federal government around $2 billion annually, and commensurate savings at the state level, according to a related press release.
Allowing EMS practitioners to treat patients at their homes or the scene of the incident and receive reimbursement for delivering those services enables EMS agencies to return to action immediately—rather than waiting for a hospital to admit their patient.
Another issue cited by officials is that many patients dial 9-1-1 to seek emergency medical treatment when they are experiencing a mental health crisis. Allowing EMS agencies to transport a patient immediately to a behavioral healthcare facility not only expedites the patient's mental health treatment but also relieves inpatient hospital mental health units from having to respond to every mental health incident.
Reducing those wait times is one important benefit of this legislation, said Scott Wooton, executive vice president of Mercy Flight Inc., while being able to bill for non transports would be another.
“Transporting to alternate destinations, as opposed to a hospital, as far as how that's going to impact EMS, it's not a huge difference. I mean, the time to transport somebody to an urgent care or a doctor's office as opposed to a hospital, is roughly about the same,” he said. “Where it could really have an impact is less critical patients going to an urgent care, as opposed to a hospital, is going to help reduce wait times at ERs. I think it's a good move in terms of utilizing the hospital and utilizing the health resources that are out there in a way that makes sense, where you're not sending patients to an ER that maybe have something that could be treated by an urgent care, because wait times in emergency rooms can be an issue.”
Providers will have to work through the logistics of finding urgent cares that will accept patients via ambulance, and that will get EMS providers back in service more quickly, he said, versus having to wait at the emergency room with a patient while he or she is getting admitted.
The other issue has been when providers complete an on-the-spot evaluation but the patient refuses transport to a hospital. Those cases have not been billable, and although this particular legislation isn’t going to change those scenarios involving private insurance and Medicare, it would ramp up payments from the Medicaid system that has not been reimbursing for such services.
“The fact that the state is now backing that, insurance will now be compelled to cover that we want to be reimbursed, that is smart legislation,” Wooton said.
“You know, we're really not in the business of just transporting patients from one place to another; we're in the business of being ready for emergencies. So anything that we can do to shorten the amount of time that it takes for us to get somebody where they need to go and get back and get ready again for the next one is exciting,” he said. “But then, in terms of the ability to bill for a treat and release, or for a patient refusal, it depends on how that actually works out.”
Given the bill’s freshness, he wasn’t familiar with how billing will work, though he pointed to Medicare as the largest payer for most emergency medical services, he said. Medicare is for people age 65 and older.
“I don’t know how the law will interact with this plan; it’s a little too early to tell the financial impact, but it’s a good thing for patients, and a good thing for people,” he said.
Wooton is happy about the other piece of legislation, the Direct Pay to Ambulance Service law, already passed and ready to take effect on Jan. 1, that will allow for direct payments from the insurance company to the provider rather than to the patient. When payments went to the patient, there would be a lag in the money being turned over to the EMS provider, Wooton said, and this measure will streamline that process and get payments where they belong more quickly.
“This will pay pay to the provider and bring insurance company to the table and are paying fairly and timely at a rate that allows us to be sustainable,” he said. “We need sustainable ambulance services, and the only way to do that is to make sure that they’re being reimbursed fairly.”
