Insurance refused to pay for her baby's air ambulance ride : Shots - Health News There are legal safeguards to protect patients from big bills like out-of-network air-ambulance rides. But insurers may not pay if they decide the ride wasn't medically necessary.

A mom's $97,000 question: How was an air-ambulance ride not medically necessary?

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AILSA CHANG, HOST:

Well, it's time for our March bill of the month. Dr. Elisabeth Rosenthal is senior contributing editor with our partner KFF Health News. Welcome, Dr. Rosenthal.

ELISABETH ROSENTHAL: Good to be here again.

CHANG: All right, so whose bill are we discussing today?

ROSENTHAL: We're looking into a bill for Sara England's baby Amari. When Amari was 3 months old, he was having difficulty breathing. So Sara rushed him to her local ER. The hospital decided he needed more specialized care.

CHANG: Right. And reporter Molly Castle Work has the rest of Sara and Amari's story.

MOLLY CASTLE WORK, BYLINE: Sara noticed Amari wasn't eating. He was wheezing and pulling at his rib cage. She was hoping the doctors in the ER would tell her it was no big deal.

SARA ENGLAND: And that everything was fine, but that was not the case. It escalated.

CASTLE WORK: Doctors intubated the 3-month-old and put him on a ventilator. Sara and her husband waited outside in the hallway for hours while doctors tried to stabilize the baby for transport. Around midnight, Sara said she was told the next step was to take Amari by air ambulance from Salinas, where they lived, to the larger hospital in San Francisco. Sara, the baby and an EMT loaded up. She recalls they were on the ground about 20 minutes later - turns out Amari had a respiratory illness called RSV. And he spent three weeks in the hospital recovering. Later, when the family got the bill for the air ambulance, it was $97,000.

ENGLAND: A little delusionally, I was like, I'm not paying this. There must be a mistake. There's no way.

CASTLE WORK: Amari was covered by Cigna health insurance. Cigna determined the plane ride wasn't medically necessary. That meant the family was on the hook for the entire bill.

ENGLAND: I felt, like, in the twilight zone. Like, what information are you basing this off of?

CASTLE WORK: In a coverage denial letter, Cigna said Amari could have taken a ground ambulance instead of a plane. Salinas is about a hundred miles from San Francisco. The insurance company said the hospital records did not show a ground ambulance, quote, "would impede timely and appropriate medical care," unquote. When she got on that plane, Sara says she was just following doctor's orders.

ENGLAND: As parents, we did not make any of the decisions other than to say, yes, we'll do that. And I don't know how else it could have gone.

CASTLE WORK: Sara's still fighting that $97,000 bill, and now it's past due.

ENGLAND: So that's something that's constantly looming and really, really stressful.

CASTLE WORK: She has appealed the bill with the insurance company twice. Both times Amari's claim was denied. Cigna maintained the air ambulance trip wasn't medically necessary.

AMARI VACA: (Laughter).

CASTLE WORK: It's been about a year since Amari was sick. Sara says he's bounced back and is doing well.

ENGLAND: I'm so, so lucky I get to be his mom. I mean, he's a miracle.

CASTLE WORK: Sara hasn't given up fighting the bill.

ENGLAND: I don't know what else to do other than to be a squeaky wheel and make as much noise about it as possible because it's not right.

CHANG: Molly Castle Work with our partner KFF Health News reported that story, and now we are back with Dr. Elisabeth Rosenthal. Dr. Rosenthal, I mean, we left off with this family facing this huge medical bill. They did have insurance, but why was that not enough in this case?

ROSENTHAL: Well, in this case, Sara's family got a balance bill. They were asked to pay the difference between what the air ambulance company charge and what the insurance company approved, which was a big, fat zero.

CHANG: But isn't that new law, the No Surprises Act, supposed to prevent exactly this kind of situation?

ROSENTHAL: Yes. The No Surprises law, passed a few years ago, is meant to urge insurers and providers to agree on a fair price. But we're finding many ways providers and insurers could get around the law. And protections only apply to care that is covered by a patient's insurance policy, and insurers only cover care that is medically necessary.

CHANG: But don't insurance policies also have, like, an out-of-pocket maximum?

ROSENTHAL: Yeah, sure. But there, again, that covers care that is medically necessary.

CHANG: Well, who gets to decide what is medically necessary?

ROSENTHAL: Well, in the case we just heard, the doctors decided that the plane ride was medically necessary. But the insurance companies have their own opinion even though they weren't there at the time. A national group of emergency medicine doctors is urging the government to require health plans to presume that a flight from one medical facility to another is medically necessary when the transport is ordered by a physician. The ER doctors want insurance companies to stop second guessing these urgent decisions. But there's plenty of blame to go around here since many air ambulance companies don't take any insurance in the first place and are owned by private equity companies. So the bills can be huge, and they're always out of network.

CHANG: But it doesn't seem like the mom in this case had much choice - right? - because the doctors were telling her this was necessary. Is there anything else, like, families such as theirs can do to fight this kind of bill?

ROSENTHAL: Well, it's tough, but you have to be really dogged. Ask doctors to write a letter or call the insurance company to question their denial. Tell the provider to request what's called a peer-to-peer review. That means a high-level review with a physician in the same specialty as the one who ordered the care. And hopefully government can close these loopholes.

CHANG: Dr. Elisabeth Rosenthal. Thank you so much.

ROSENTHAL: Thanks for having me.

CHANG: And if you have a confusing or outrageous medical bill that you want us to review, please go to NPR's Shots blog and tell us all about it.

(SOUNDBITE OF STORMZY SONG, "FIRE + WATER")

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