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How to appeal Medicare denial of ambulance ride?

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    How to appeal Medicare denial of ambulance ride?

    I took a non-emergency ambulance ride from the ER back to my house last year but Medicare denied it. Anyone had this happen?
    Last edited by xsfxsf; 15 Jan 2022, 3:38 AM.

    #2
    Don't try and fight Medicare but talk with the hospital and see if they will absorb the cost. They always have for me.

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      #3
      Medicare rarely covers ambulance costs even going to the ER unless you are admitted. Who arranged the trip home (you or the hospital?).

      (KLD)
      The SCI-Nurses are advanced practice nurses specializing in SCI/D care. They are available to answer questions, provide education, and make suggestions which you should always discuss with your physician/primary health care provider before implementing. Medical diagnosis is not provided, nor do the SCI-Nurses provide nursing or medical care through their responses on the CareCure forums.

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        #4
        It depends what billing code (CPT) they filed it under. There are 7 categories of land (and water) based ambulance services in the codes and Medicare doesn't reimburse for all of them; only the emergency and other medically necessary codes. Unless you can show (ie your doctor orders it) that you were at some medical risk for being transported otherwise, then they probably billed the non-emergent (A0426) plus the "residential" modifier (-R), which is essentially an expensive taxi ride that they will never pay for.

        If you could get the hospital to bill the "specialty care" transport code (A0434), then you might be able to have it reimbursed. Assuming that would not be "upcoding" and would actually apply to your medical needs and status. If a doctor said "take the ambulance home", then this might be possible.

        Otherwise, unless you needed basic life support, or were being transported from one facility to another for medically necessary treatment, this will be a losing battle, trying to get them to pay, IMO.
        "I have great faith in fools; self-confidence my friends call it." - Edgar Allen Poe

        "If you only know your side of an issue, you know nothing." -John Stuart Mill, On Liberty

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          #5
          Originally posted by Oddity View Post
          It depends what billing code (CPT) they filed it under. There are 7 categories of land (and water) based ambulance services in the codes and Medicare doesn't reimburse for all of them; only the emergency and other medically necessary codes. Unless you can show (ie your doctor orders it) that you were at some medical risk for being transported otherwise, then they probably billed the non-emergent (A0426) plus the "residential" modifier (-R), which is essentially an expensive taxi ride that they will never pay for.

          If you could get the hospital to bill the "specialty care" transport code (A0434), then you might be able to have it reimbursed. Assuming that would not be "upcoding" and would actually apply to your medical needs and status. If a doctor said "take the ambulance home", then this might be possible.

          Otherwise, unless you needed basic life support, or were being transported from one facility to another for medically necessary treatment, this will be a losing battle, trying to get them to pay, IMO.
          When GJ was transported to the hospital 2.5 years ago, he was in a lot of pain (later diagnosed as a volvulus, aka twisted intestine) and I was really afraid to get him into his wheelchair and drive him to the hospital, so I called an ambulance (first time we used ambulance services in 38 years). The ambulance claim was denied by Medicare. As Oddity mentioned above, the coding for the service was not correct. But, in GJ's case, it was not the hospital that coded the service, it was the ambulance company.

          After GJ passed, I was billed $2,500.00 for the ambulance service. I went through the Medicare appeals process (waste of time) to get Medicare to cover the service. Denied! Denied! Denied!

          Finally, I called HICAP (Health Insurance Advocacy Program) in my area. I got lucky, because I talked to a volunteer who was a retired lawyer and who specialized in ambulance claims for HICAP clients. He knew someone in admin at the ambulance company. He made a call to his contact and explained the problem. Within 2 days, I got a call from his contact who told me she had the claim re-coded and that it had been re-submitted to Medicare. Within 2 weeks, I got an explanation of benefits from Medicare that the claim had been processed and covered.

          Seems in my area, this ambulance company only uses the "specialty care" code if the person is non responsive or has open bleeding wounds.

          Wish you luck in getting the claim re-coded.

          NL

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