Sara England was putting together Ghostbusters costumes for Halloween when she noticed her baby wasnt doing well.
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Her 3-month-old son, Amari Vaca, had undergone open-heart surgery two months before, so she called his cardiologist, who recommended getting him checked out. England assigned Amaris grandparents to trick-or-treat duty with his three older siblings and headed to the local emergency room.
Once England and the baby arrived at Natividad Medical Center in Salinas, California, she said, doctors could see Amari was struggling to breathe and told her that he needed specialized care immediately, from whichever of two major hospitals in the region had an opening first.
Even as they talked, Amari was declining rapidly, his mother said. Doctors put a tube down his throat and used a bag to manually push air into his lungs for over an hour to keep his oxygen levels up until he was stable enough to switch to a ventilator.
According to England, late that night, when doctors said the baby was stable enough to travel, his medical team told her that a bed had opened up at the University of California-San Francisco Medical Center and that staffers there were ready to receive him.
She, her son, and an EMT boarded a small plane around midnight. Ground ambulances carried them between the hospitals and airports.
Amari was diagnosed with respiratory syncytial virus, or RSV, and spent three weeks in the hospital before recovering and returning home.
Then the bill came.
The Patient: Amari Vaca, now 1, who was covered by a Cigna policy sponsored by his fathers employer at the time.
Medical Services: An 86-mile air-ambulance flight from Salinas to San Francisco.
Service Provider: Reach Medical Holdings, which is part of Global Medical Response, an industry giant backed by private equity investors. Global Medical Response operates in all 50 states and has said it has a total of 498 helicopters and airplanes. It is out-of-network with Amaris Cigna plan.
Total Bill: $97,599. Cigna declined to cover any part of the bill.
What Gives: Legal safeguards are in place to protect patients from big bills for some out-of-network care, including air-ambulance rides.
Medical billing experts said the No Surprises Act, a federal law enacted in 2022, could have protected Amaris family from receiving the $97,000 balance bill, leaving the insurer and the air-ambulance provider to determine fair payment according to the law. But the protections apply only to care that health plans determine is medically necessary and insurers get to define what that means in each case.
According to its coverage denial letter, Cigna determined that Amaris air-ambulance ride was not medically necessary. The insurer cited its reasoning: He could have taken a ground ambulance instead of a plane to cover the nearly 100 roadway miles between Salinas and San Francisco.
I thought there must have been a mistake, England said. Theres no way we can pay this. Is this a real thing? Email Sign-Up
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In the letter, Cigna said Amaris records did not show that other methods of transportation were medically contraindicated or not feasible. The health plan also noted the absence of documentation that he could not be reached by a ground ambulance for pickup or that a ground ambulance would be unfeasible because of great distances or other obstacles.
Lastly, it said records did not show a ground ambulance would impede timely and appropriate medical care.
When KFF Health News asked Cigna what records were referenced when making this decision, a spokesperson declined to respond.
Caitlin Donovan, a spokesperson for the National Patient Advocate Foundation, said that even though Amaris bill isnt technically in violation of the No Surprises Act, the situation is exactly what the law was designed to avoid.
What they’re basically saying is that the parents should have opted against the advice of the physician, Donovan said. That’s insane. I know medical necessity is this nebulous term, but it seems like it’s becoming a catch-all for turning down patients. England says she was stunned when insurance denied coverage for her infant sons air-ambulance ride on the grounds that it was not medically necessary. I thought there must have been a mistake, she says. Theres no way we can pay this.(Kevin Painchaud for KFF Health News)
On Feb. 5, the National Association of Emergency Medical Services Physicians said that since the No Surprises Act was enacted two years ago, it has seen a jump in claim denials based on lack of medical necessity, predominantly for air-ambulance transports between facilities.
In a letter to federal health officials, the group cited reasons commonly given for inappropriate medical-necessity denials observed by some of its 2,000 members, such as the patient should have been taken elsewhere or the patient could have been transported by ground ambulance.
The association urged the government to require that health plans presume medical necessity for inter-facility air transports ordered by a physician at a hospital, subject to a retrospective review.
Such decisions are often made under dire circumstances when a hospital is not capable of caring for or stabilizing a particular patient or lacks the clinical resources to stabilize a patient with a certain clinical diagnosis, the groups president, Jos Cabaas, wrote in the letter. Clinical determinations made by a referring physician (or another qualified medical professional) should not be second-guessed by a plan.
Patricia Kelmar, a health policy expert and senior director with the U.S. Public Interest Research Groups, noted, however, that hospitals could familiarize themselves with local health plans, for example, and establish protocol, so that before they call an air ambulance, they know if there are in-network alternatives and, if not, what items the plan needs to justify the claim and provide payment.
The hospitals who live and breathe and work in our communities should be considering the individuals who come to them every day, Kelmar said. I understand in emergency situations you generally have a limited amount of time, but, in most situations, you should be familiar with the plans so you can work within the confines of the patients health insurance.
England said Cignas denial particularly upset her.
As parents, we did not make any of the decisions other than to say, yes, well do that, she said. I don’t know how else it could have gone.
The Resolution: England twice appealed the air-ambulance charge to the insurer, but both times Cigna rejected the claim, maintaining that medical necessity had not been established.
The final step of the appeals process is an external review, in which a third party evaluates the case. England said staff members at Natividad Medical Center in Salinas which arranged Amaris transport declined to write an appeal letter on his behalf, explaining to her that doing so is against the facilitys policy.
Using her sons medical records, which the Natividad staff provided, England said she is writing a letter herself to assert why the air ambulance was medically necessary.
Andrea Rosenberg, a spokesperson for Natividad Medical Center, said the hospital focuses on maintaining the highest standards of health care and patient well-being.
Despite receiving a waiver from England authorizing the medical center to discuss Amaris case, Rosenberg did not respond to questions from KFF Health News, citing privacy issues. A Cigna spokesperson told KFF Health News that the insurer has in-network alternatives to the out-of-network ambulance provider, but despite receivinga waiver authorizing Cigna to discuss Amaris case declined to answer other questions.
It is disappointing that CALSTAR/REACH is attempting to collect this egregious balance from the patients family, the Cigna spokesperson, Justine Sessions, said in an email, referring to the air-ambulance provider. We are working diligently to try to resolve this for the family.
On March 13, weeks after being contacted by KFF Health News, England said, a Cigna representative contacted her and offered assistance with her final appeal, the one reviewed by a third party. The representative also told her the insurer had attempted to contact the ambulance provider but had been unable to resolve the bill with them.
Global Medical Response, the ambulance provider, declined to comment.
England said she and her husband have set aside two hours each week for him to take care of their four kids while she shuts herself in her room and makes calls about their medical bills.
Its just another stress, she said. Another thing to get in the way of us being able to enjoy our family. England says the insurer’s denial particularly upsets her because she and her husband didnt make any decisions about their sons transportation; they were simply doing what doctors told them to do.(Kevin Painchaud for KFF Health News)
The Takeaway: Kelmar said she encourages patients to appeal bills that seem inaccurate. Even if the plan denies it internally, push forward to an external review so someone outside the company has a chance to review, she said.
In the case of medical necessity denials, Kelmar recommended patients work with the medical provider to provide more information to the insurance company to underscore why an emergency transport was required. More from Bill of the Month Without Medicare Part Bs Shield, Patients Family Owes $81,000 for a Single Air-Ambulance Flight Feb 27, 2024 The Colonoscopies Were Free. But the Surgical Trays Came With $600 Price Tags. Jan 25, 2024 When a Quick Telehealth Visit Yields Multiple Surprises Beyond a Big Bill Dec 19, 2023
Doctors who write a letter or make a call to a patients insurer explaining a decision can also ask for a peer-to-peer review, meaning they would discuss the case with a medical expert in their field.
Kelmar said patients with employer-sponsored health plans can ask their employers human resources department to advocate for them with the health plan. Its in the employers best interest since they often pay a lot for these health plans, she said.
No matter what, Kelmar said, patients shouldnt let fear stop them from appealing a medical bill. Patients who appeal have a high likelihood of winning, she said.
Patients with government health coverage can further appeal insurance denials by filing a complaint with the Centers for Medicare & Medicaid Services. Those who believe they have received an inappropriate bill from an out-of-network provider can call the No Surprises Act help desk at 1-800-985-3059.
Bill of the Month is a crowdsourced investigation by KFF Health News and NPR that dissects and explains medical bills. Do you have an interesting medical bill you want to share with us? Tell us about it!
This article was produced by KFF Health News, which publishes California Healthline, an editorially independent service of the California Health Care Foundation.
Molly Castle Work: [email protected], @mollycastlework Related Topics California Insurance States Bill Of The Month Children's Health Emergency Medicine Hospitals Investigation Contact Us Submit a Story Tip
