Your family member is a patient in a medical facility far from home. Will Medicare pay to transport your patient to a medical facility closer to home? It depends…
Figuring out whether Medicare will cover the cost of your air ambulance can feel like navigating a maze. Air ambulance is very costly, and the decision to transport a patient often depends on whether Medicare will pay for the service. Medicare does not give authorization ahead of the transport, only reviewing cases after the fact. Therefore, understanding which transports are covered may be critical to your choice
This blog post hopefully will make the answer clear for you. However, if you have further questions, please call us at 800-948-1220 or email us at firstname.lastname@example.org and we would be happy to discuss them with you.
To Know If Medicare Will Pay For Air Ambulance, The Following Questions Must Be Answered:
Is this a pre-hospital, emergency air ambulance?
If so, Medicare may pay if:
- A ground ambulance cannot get to you where you are.
- There is a great distance to travel or another obstacle involved in getting you to the nearest appropriate facility.
- A doctor determines that your life would be threatened by ground transport.
However, Medicare will not pay for emergency air ambulance if the patient could be safely transported by ground ambulance.
Medicare will also not pay if you choose to take the patient to a facility farther than the nearest facility that could handle the emergency.
In the vast majority of cases, Medicare will not pay for emergency air ambulance from a foreign country to the United States. In very few cases, if the patient is located close to the US border and the closest hospital is a U.S. hospital, Medicare may pay to transfer an emergency, pre-hospital patient across the U.S. border.
Is your patient is already at a medical facility? Medicare reviews these cases differently. Air ambulance from one facility to another is generally not considered an emergency transport. Medicare calls these transports inter-facility transports.
Unfortunately, communication errors often occur between Medicare phone customer service and patient family members when determining if transports are covered. The guidelines are clear for pre-hospital transports, but communications have historically been less clear regarding inter-facility transfers. The written guidelines are specific, even if convoluted.
If Yours Is An Inter-Facility Transport, Additional Questions Must Be Asked:
Why is the patient being transferred from a facility to another facility?
Medicare may pay if:
- The current facility is incapable of caring for the patient.
- AND the receiving facility is the nearest facility that can adequately take care of the patient.
- AND the patient can only be transferred by air ambulance.
However, Medicare's sole judgment determines if the current facility is inadequate, and if so, which facility is the nearest that is adequate. Medicare also determines if the patient could have been transported by a less costly method such as ground ambulance.
Is the treatment being sought at the receiving facility deemed by Medicare to be experimental?
If the treatment being sought is experimental or is not covered by Medicare, then Medicare will not pay for the transport.
Is the patient currently outside the United States?
Medicare does not pay to transport a patient from a facility outside of the United States back to the United States. For this reason, those travelling to other countries should seriously consider buying travel insurance that covers transport back to country of origin.
The following are examples of cases in which Medicare will NOT pay for air ambulance:
Example 1: Distance formula
Mom lives in New York and while visiting family in Florida, she had a heart attack. Her doctors are all in New York and have asked that she be transferred back to New York. Her doctors in Florida state that the only way she can travel back to New York is by air ambulance.
Medicare will not pay because there are adequate facilities in Florida.
Example 2: Adequate treatment
Dad has a dissected aortic aneurysm and his doctors in California state that a hospital in Texas can give better operation results.
Medicare will not pay to transport patients to hospitals that have statistically better results because either:
- a. The sending hospital in California performs similar operations
- b. Another hospital in California performs similar operations.
Example 3: Convenience of the family
Granddad has been living in Arizona and has recently been diagnosed with terminal cancer. He now wants to move back to Illinois to be near family for his remaining days.
Medicare will not pay to move the patient near to family. While the patient most likely would have a better quality of life to be near family, Medicare does not take family support into account. The patient can be adequately cared for in Arizona according to Medicare standards.
Example 4: International travel
Grandma travelled to Europe for business and fell ill with Pneumonia. She will require several months of institutional recovery.
Medicare will not transfer a patient from another country to the United States.
Example 5: Experimental treatment
Mom was recently diagnosed with terminal cancer and an experimental cancer trial treatment is available in Florida.
Medicare will not transport patients for experimental treatments.
So there you have it. The vast majority of inter-facility air ambulance transports are, unfortunately, not covered by Medicare…. but some transports, not otherwise eliminated above, are covered. It will be up to you to pursue reimbursement from Medicare. Your air ambulance provider should be with you every step of the way.
Your air ambulance company will work with you to submit a HCFA 1500 claim form to Medicare on your behalf. Be sure not to duplicate their effort with a submittal on your own, for this will confuse the Medicare system and may delay the process. Answers from Medicare following the claim form may take up to 30 days so be prepared.
After the claim is submitted, Medicare may ask for additional supporting documentation. Be sure to get documentation and letters from both the sending facility and receiving facility that prove medical necessity for air ambulance. In addition, prior to transporting your patient, discuss with the sending facility if there are other, closer receiving facilities that could meet the distance formula required by Medicare. You may also need to submit flight notes from the air ambulance company. We will submit ours as a matter of course on your behalf.
When Medicare receives your claim, the claim will first be tested to ensure it meets the distance formula ie: is the receiving facility the closest facility that can care for the patient. If your transport passes the distance test, then Medicare will determine if it passes medical necessity requirements. Because of the cost of inter-facility air ambulance, do not be surprised if your claim is initially denied automatically by your Medicare claims processor on one of these two reasons, even if ultimately it passes both tests.
If your claim is denied, you will be sent a denial letter with reasons for denial. Once denied, if you still believe your case deserves further attention, you can appeal. A further step of a judicial hearing, a legal proceeding, may be required. The hearing is generally heard by a judge over the phone. The process can be lengthy and cumbersome. Your air ambulance provider should support your needs through the entire process, including being available for the hearing, if necessary.
You will need to pay your air ambulance provider up front out of pocket prior to the transport. Before committing to such a costly expenditure, please take the time to thoroughly understand if your costs will be reimbursed. While most Inter-facility air ambulance transfers are not covered by Medicare, some are. Please review your case ahead of a transfer with your air ambulance provider to ensure that air ambulance is the right choice, even if Medicare will not ultimately reimburse you. Knowing whether you will be reimbursed can be definitively answered prior to your transport in most cases.