Advocacy in Action | Ambulance Bill Audit and Recovery

An ambulance company balance billed the member for $1,787.87. The member did not understand why so they contacted their Patient Advocate for assistance. The Patient Advocate went to work to see how she could help. When checking the insurance plan and benefits, the Patient Advocate learned the ambulance service used was an in‐network service provider. The Patient Advocate also found the member had met both her deductible and her out-of-pocket maximum and should not owe anything on the bill. After checking the claim payment and auditing the bill, the Patient Advocate was able to determine the company incorrectly balance billed the member. The ambulance company was contacted and advised they were an in‐network service provider and should not be balance billing the member. They denied being an in‐network service provider and did not believe anything the Patient Advocate was saying. The Patient Advocate faxed over a copy of the claims Explanation of Benefits showing the service provider to be in‐network, along with a copy of the web directory from the carrier website which also showed the provider to be in‐network. The service provider still refused to acknowledge they were an in‐network service provider and would not adjust the bill. The Patient Advocate then reached out to the insurance carrier and explained the situation. The claims manager immediately contacted the Director of Network Access who in turn contacted the service provider to confirm they were an in‐network service provider. The Director of Network Access explained to the ambulance company they had contractual obligations to the insurance carrier, and they should immediately cease their balance billing efforts. The conversation did the trick, and the member’s account was adjusted to a zero balance saving the member over $1,700.