In this guide 4 sections
Ambulance bills during hospice can go to different places. The key questions are whether each trip was related to the terminal illness, whether the hospice arranged it, and whether the ambulance met Medicare coverage rules.
Who should handle each ambulance bill?
If the hospital trip was related to the terminal illness or a related condition, it generally needed to be arranged by the hospice team. Ask the hospice billing office to review the ambulance claim under the hospice benefit.
If the trip was unrelated to the terminal illness and related conditions, Original Medicare may pay for covered services. The ambulance still must meet Medicare Part B rules, including medical necessity and transportation to the nearest appropriate facility.
If a trip was related to the terminal illness but was not arranged by the hospice, Medicare warns that the patient might be responsible for the entire cost. Ask the hospice to review the circumstances before accepting that answer.
What to do after a denial
- 1.Ask the hospice to decide in writing whether each ambulance trip was related to the terminal illness and whether the hospice arranged or authorized it.
- 2.Request the hospice election statement and any addendum listing services the hospice considers unrelated. Medicare says the hospice must provide the requested list within 3 to 5 days, depending on when it was requested.
- 3.Ask the ambulance billing office where each claim was sent. Give it the hospice decision, hospice authorization, denial notice, and hospital records that explain why an ambulance was needed.
- 4.Follow the instructions and deadline on the denial notice. Appeal if you disagree with the decision. Ask the ambulance supplier or another provider for records that strengthen the appeal.
What should the appeal explain?
Address each trip separately. State why the ambulance was needed, why another vehicle could have endangered the patient, where the ambulance went, whether that was the nearest appropriate facility, and whether the hospice arranged the trip. Include the hospice determination and supporting records.
What could the patient owe?
For an ambulance trip covered under Medicare Part B, the patient generally pays 20% of the Medicare approved amount after the Part B deductible. Other insurance may affect the final amount. Covered hospice care from a Medicare approved hospice generally has no charge, although limited hospice cost sharing can apply to certain drugs and inpatient respite care.
Questions families ask
Who pays when the ambulance trip was related to the terminal illness?
The hospice benefit should cover care related to the terminal illness when it was provided or arranged by the hospice team. Ask the hospice billing office to review the claim and explain its decision in writing.
Who pays when the ambulance trip was unrelated to hospice?
Original Medicare may cover the trip if it meets Part B ambulance rules. Those rules include medical necessity and transportation to the nearest appropriate facility able to provide the needed care.
Can a Medicare Advantage denial be appealed?
Yes. A person can appeal when a Medicare Advantage plan refuses to pay for a service already received. Use the instructions and deadline in the written denial notice.
Where can a family get free appeal help?
The State Health Insurance Assistance Program provides free, personalized Medicare counseling. Medicare directs people to SHIP at shiphelp.org.
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