Air ambulance company takes leukemia patient for a high-priced ride : Shots - Health News Diagnosed with aggressive leukemia while on a trip to Wyoming, a man thought his insurance would cover an air ambulance ride home to North Carolina. Instead, he got hit with an astronomical bill.

The case of the $489,000 air ambulance ride

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ARI SHAPIRO, HOST:

Who decides whether something is medically necessary or not? That question's at the heart of our Medical Bill of the Month. Dr. Elisabeth Rosenthal is the editor-in-chief of our partner Kaiser Health News, and she's here to tell us about it. Dr. Rosenthal, welcome back.

ELISABETH ROSENTHAL: Thanks, Ari. Good to be here.

SHAPIRO: Who do you want to introduce us to today?

ROSENTHAL: Today we meet Sean and Rebekah Deines. They're a young couple who live in western North Carolina.

SHAPIRO: OK. Reporter Stephanie O'Neill caught up with Sean Deines. And let's listen to what happened to him, and then we'll come back and discuss his bill.

STEPHANIE O'NEILL, BYLINE: When the pandemic caused Sean Deines to lose his job as a bartender and graphic artist in his native North Carolina, he and his wife headed west to stay for a bit with Sean's grandfather on his Wyoming homestead.

SEAN DEINES: I was doing a lot of fishing, camping, trying to enjoy as much of life as we could.

O'NEILL: But then something totally unexpected happened to 32-year-old Sean.

DEINES: Around the middle of October, I began to experience some serious leg swelling in actually both legs, which was quite unusual.

O'NEILL: The swelling continued and over a few weeks became painful. Fatigue set in. Sean's wife Rebekah urged him to get blood tests at a local urgent care. And within 24 hours of doing so, Sean got a call that turned his life upside down.

DEINES: The lady on the other end, she said, get yourself to an emergency room, you know, as fast as you can. Your white blood cell count is extremely high.

O'NEILL: The couple drove more than three hours to a regional hospital in Casper, Wyo. Doctors there ran tests that prompted them to transfer Sean to a large Denver hospital. His diagnosis - a fast-growing blood cancer called acute lymphoblastic leukemia.

DEINES: Basically what happens is the immature white blood cells basically start to clog the body in a sense, and it almost chokes the body out.

O'NEILL: The needed treatment would require Sean remain hospitalized for nearly a month at the end of 2020. But Sean had no family in Denver. His parents lived just 30 minutes from Duke University Hospital in Durham, N.C. But he'd need medical care during the 1,400-mile trip home.

DEINES: Then the next step would be, how do we get back to Duke?

O'NEILL: His mom found an Arizona-based air ambulance company called Angel MedFlight. The company said it would figure out payment with Sean's insurer and that they could take him almost immediately. A relieved Sean flew to Duke and underwent 26 days of intense inpatient cancer treatments. The bill for the ground and air ambulances added up to almost a half million dollars. In March 2021, Blue Cross Blue Shield of North Carolina sent Sean a big chunk of that total, a check for $72,000 in his name.

DEINES: What we proceeded to do was forward that check to Angel MedFlight, and that was basically what we thought was the end of that whole payment issue.

O'NEILL: But just weeks later, in June, Blue Cross demanded Sean pay back all the money which he no longer had.

DEINES: We were speechless when we received a refund request for $72,000. That's a - you know, a nice Tesla or - take your pick - any nice sports car.

O'NEILL: So then began the quest to figure out what happened. Why had the insurer paid the claim, then, months later, demand its return?

DEINES: But nobody could ever really give us any answers. And I'll be honest, I still don't really know why the initial payment was ever made if they had reservations about, you know, paying for it.

O'NEILL: Sean Deines, whose leukemia is now in remission, says this past September, Blue Cross threatened to send him to collections. For NPR News, I'm Stephanie O'Neill.

SHAPIRO: Wow. Dr. Rosenthal, there is so much to unpack here. His insurer was sending him to collections because he didn't pay back $72,000 that he had already given to the air ambulance company that they had sent him a check for. Explain what was happening here.

ROSENTHAL: It's hard to explain, isn't it? That was the totally surreal situation Sean was in when he wrote to us at Bill of the Month.

SHAPIRO: And what's his situation now?

ROSENTHAL: Well, we started making calls. And the good news, as so often happens, is that the dispute between the two parties that Sean was in the middle of was resolved. They both backed off.

SHAPIRO: The insurer and the ambulance?

ROSENTHAL: Yes, that's right. The insurer now says it will not send Sean to collections and has stopped seeking the $72,000 back.

SHAPIRO: I was also struck by that initial figure, half a million dollars for ambulances alone. How did they get from that figure to this $72,000 payment?

ROSENTHAL: The air ambulance company wasn't in Sean's insurance network. And, yes, those initial charges were just outlandish. There's no basis in reality. We were told by the insurer that the $72,000 was just for the ground ambulance between the hospitals and the airports.

SHAPIRO: Why did the insurance company change its mind and say, we shouldn't have paid this; you owe us $72,000 all of a sudden?

ROSENTHAL: This crazy case revolves around the question of medical necessity and who gets to make that call. The insurance company reviewed the case and said there was no medical necessity for Sean to leave the hospital in Denver.

SHAPIRO: So it didn't matter that Sean had no family in Denver, that he didn't live in Denver, that he would need to spend a month getting treated?

ROSENTHAL: It mattered to Sean, of course, but it didn't to the insurance company.

SHAPIRO: What about this new law that's supposed to protect people from surprise bills, including air ambulance bills?

ROSENTHAL: That's right. There is this No Surprises Act that started up this year on January 1. But Sean's case underlines some weak spots in that protection. First of all, the insurance companies can say a trip or a procedure was not medically necessary. And also, the law doesn't somehow cover ground ambulances, which is kind of crazy. Ground ambulances are often out-of-network, and they're way, way high.

SHAPIRO: Are there other things that people should watch out for?

ROSENTHAL: Sure. There are a bunch of loopholes. In non-emergency cases, the new law requires out-of-network providers give patients a good faith estimate of their charges. Well, if their estimate is $489,000, is that really a choice? I don't think so.

SHAPIRO: Well, I'm happy to hear that Sean is doing better and that this billing nightmare is over for him. Dr. Elisabeth Rosenthal, thank you for telling us about it.

ROSENTHAL: I'm glad we could help him, and thank you.

SHAPIRO: And if you have an outrageous or confusing medical bill, please go to NPR's Shots blog, and tell us about it.

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