Thursday, June 5, 2014

It's a bird, it's a plane, it's superbill

There are, as they say, few certainties in life.  One that can be added to the list may be that any  claim that begins with a helicopter ride is not a good day for the injured worker or the risk manager.

Section 287.140 provides a transportation benefit and  requires employers to provide medical services including “ambulance” that “reasonably [may] be required after an injury or disability.”  Missouri employers may also face significant costs for ground or air ambulances for initially responding to an accident or as part of the ongoing cure or medical relief of injuries. 

Medicare regulations provide some interpretative guidance as to what might be reasonably related.  

 “After an injury or disability”

The employer does not owe a transportation benefit unless it responds to an “injury or disability”.  The court of appeals found an uninsured worker fainted at work, the ambulance was called over the objection of the worker’s spouse, and the court found the employer did not owe the ambulance bill  because the worker failed to prove her fall and any need for an ambulance flowed from a work injury.  Crumpler v Walmart, 286 S.W.3d 270 (Mo. App. 2009). 

 “Reasonably required”

 Medicare prohibits transportation benefits unless the need for transportation  relates to Medicare-covered services.  It’s one thing to have an air ambulance take a worker to a trauma one center.  It is quite another thing to ask a helicopter to drop a worker off at his house.  There is an actual federal regulation on this point.     Ground transportation may be a reasonable alternative if the distance to the appropriate medical facility is close.

 Medicare prohibits transportation benefits beyond the nearest “appropriate” facility. This is clearly defined in Chapter 10.3 of the Medicare Benefit Policy Manual that  “transport is covered to the nearest appropriate facility to obtain necessary diagnostic  and or therapeutic services.” Transportation to a more remote facility does not flow from medical necessity. 

Natural and probable consequence

Transportation in an ambulances and fixed or rotary wing aircraft represent unique risks.  From 2003 to 2008 a total of 125 people died in air ambulances.  The FAA Modernization and Reform Act of 2012 describes many risks different from the ordinary public such as flying into tall objects.   It requires pilots to figure out what tall objects might be in their flight path to avoid this type of thing from happening.  This is really a federal regulation. 

MSA my helicopter ride

An often-neglected aspect of the work comp MSA is for Medicare-covered  expenses for future transportation costs.  Missouri providers alone charged 19.9 million in transportation costs.  There are 6.5 million in helicopter rides for Missouri alone according to a Pro Publica report.  There may be an additional  future aspect for transportation costs which are not Medicare-covered as Medicare pays only 80% of its fee schedule. 

 Can fee resolution resolve a $30,000 helicopter bill?

Disputes for bills about air ambulances are likely pre-empted by  49 USC 41713.
The use of air ambulances provides unique capabilities of first responders to address life-threatening situations when an injured person is  far from an appropriate medical facility.  National fee schedules provide some basis to challenge skyhigh bills in the absence of a state fee schedule.  The reasonableness of calling ambulance services is often a matter of timing whether there is a bona-fide emergency or not. 

Additional Sources:

Section 4531 (b) (2) of the Balanced Budget Act (BBA) of 1997 added a new section 1834 (l) to the Social Security Act which mandated the implementation of a national fee schedule for ambulance services.
Fee schedule under Medicare for fixed and rotary wing ambulance
One air ambulance provider in St. Louis submitted to Medicare charges to transported nearly 1300 patients, about half the number of the leading provider in Kansas city, according to Pro Publica.