Medicare & Health Insurance Plan

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1. If an insurance provider paid only 80% of the bill, who pays the remainder?  Is the patient responsible for any balance not paid by health insurance?

2. Why is an ambulance bill sent to a patient's insurance provider and not to the patient's home?

3. If a patient has more than one insurance provider, will the LAFD bill the other insurance for the balance?  Will LAFD re-bill insurance providers if they receive new information?

4. What does it mean when Medicare denies a claim as "not medically necessary" or otherwise refuses to pay the bill?  Is the patient responsible for payment?

5. What happens to the balance on an account if Medicare does not pay the full amount?

1. If an insurance provider paid only 80% of the bill, who pays the remainder?  Is the patient responsible for any balance not paid by health insurance?

Depending on a patient's health insurance coverage and benefits, an insurance provider may deny a claim or pay only a portion of the bill.  A patient may have a high deductible or a plan requiring co-payments.  If a patient has secondary or additional insurance, a claim may be filed with those providers as well but, ultimately, any unpaid balance is the responsibility of the patient. The LAFD does not contract with private insurance companies and City policy establishes full cost recovery associated with providing ambulance transportation to patients.  The Explanation of Benefits (EOB) provided by an insurance company should explain what portion of the ambulance bill is the patient's responsibility.

2. Why is an ambulance bill sent to a patient's insurance provider and not to the patient's home?

Patients transported by LAFD ambulance are agreeing to allow the LAFD to bill their insurance provider(s) and collect payment from those insurance providers in-lieu of being billed directly and having to seek reimbursement from their provider.  Patients will receive a bill if the LAFD is unable to collect payment from an insurance provider or if there is any unpaid balance.

3. If a patient has more than one insurance provider, will the LAFD bill the other insurance for the balance?  Will LAFD re-bill insurance providers if they receive new information?

If a patient's account has a balance and they provide new or updated insurance, the LAFD will attempt to file a new claim.  It should be noted that an insurance provider may deny a claim if it is not filed within a certain time frame.  Filing deadlines vary by insurance carrier and the LAFD is not responsible for the failure of patients to provide valid insurance information in a timely manner.

4. What does it mean when Medicare denies a claim as "not medically necessary" or otherwise refuses to pay the bill?  Is the patient responsible for payment?

An ambulance transport may not meet Medicare's strict criteria for medical necessity and the patient is responsible for the ambulance bill.  For Medicare to cover an ambulance transport, a patient's medical condition at the time of transport must have been such that transportation by any other means could have endangered their health. More information about medical necessity, including a patient's right to appeal Medicare’s decision, may be found at Medicare.gov or by calling 1-800-MEDICARE.

5. What happens to the balance on an account if Medicare does not pay the full amount?

If Medicare does not pay the full amount due on an ambulance bill the LAFD will attempt to bill any secondary or additional insurance on file for the patient but, ultimately, the patient may be responsible for the remaining balance.  The  Explanation of Benefits (EOB) provided by Medicare will identify the patient's financial responsibility.

 

 

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