$474,725: This 'surprise' medical bill may be the biggest you've ever seen

After suffering a debilitating stroke, Kristina Cunningham was transported from Wichita, Kansas, to Boston on an air ambulance, and though both her doctors and insurer deemed the transport medically necessary, she later received a potentially record-setting $474,725 bill, Martha Bebinger reports for WBUR.

'Surprise' medical bills, explained in 5 charts

According to Bebinger, who published the story in collaboration with Kaiser Health News and NPR, Cunningham's bill reveals a growing trend of air ambulance services charging privately insured patients at exorbitant prices.

What happened to Kristina Cunningham

Last summer, 34-year-old Cunningham attended a wedding in Wichita and suffered a stroke that left her unable to use her right arm and to speak clearly. After six days, Cunningham still had two blood clots at the base of her brain and doctors at the small Kansas hospital where Cunningham was treated said she needed a neurosurgeon.

Cunningham's father, Jim Royer, said both her doctors and insurer, CareFirst BlueCross BlueShield, eventually agreed to fly Cunningham via an Angel MedFlight Learjet to Massachusetts General Hospital, where she could be near her family.

At the time, Royer said they'd expected the flight to be covered, especially since it was "supposedly preapproved by the insurer before any flight took place." But in August the received a bill for the flight totaling $474,725. According to Royer, the bill encompassed four charges, the largest of which was a $275 per-mile charge, totaling $389,125. The total, Royer said, "would force [Cunningham] into bankruptcy." CareFirst paid $14,304.55 of the cost, leaving Cunningham responsible for the $460,420 that remained unpaid.

Chuck Bell, program director for the advocacy division at Consumer Reports called the bill "outrageous," and said "it's larger than any surprise medical bill [he's] personally seen."

What's behind the big bills?

While Cunningham may have experienced one of the surprise highest medical bills, her experience highlights a growing trend of privately insured patients receiving "excessively high air ambulance bills," Bebinger reports.

According to the Association of Air Medical Services (AAMS), a trade group, air ambulance companies charge patients with private insurance more for the service to offset the money lost when transporting patients who are self-pay or have Medicare or Medicaid.

Andrew Bess, COO of Angel MedFlight, said, "The amount [the companies] receive per flight is a fraction of the billed charge."

Christopher Eastlee, VP of government relations for AAMS, in a statement said, "Medicare pays about 60% of the cost of the flight. Medicaid pays 35% or less. Self-paid patients pay a few cents on the dollar. And that has led to a crisis of being able to sustain the service." Eastlee noted that his cost data is only for emergency helicopter transportation, not medical jets that Cunningham flew on.

According to Bebinger, there's no industry standard or guidelines to set reasonable charges for medical flights, meaning charges can vary greatly. For example, Bebinger reports Medicare would pay $8.65 per mile for an air ambulance similar to the one that transported Cunningham, compared with the $275 per mile Angel MedFlight charged Cunningham.

Scott Graham, a spokesperson for CareFirst, said that cases like Cunningham's are "an issue because companies like Angel MedFlight typically do not contract with health insurers on negotiated rates."

Can regulations curb air ambulance prices?

In response to high ambulance bills, lawmakers are eyeing stricter regulations for air ambulance companies.

At the federal level, the Senate in October 2018 voted 93 to 6 to pass a transportation reauthorization bill that increased federal reporting requirements for air ambulances. President Trump signed the measure into law last year.

At the state level, in Massachusetts, ground-based ambulance companies are barred from balance billing, or charging patients the remaining balance after insurance reimbursement in the way that MedFlight charged Cunningham. But since air ambulances only have to abide by federal aviation laws, Cunningham was fully responsible for the remaining balance.

After media inquiries for the story, CareFirst said its initial reimbursement to Angel MedFlight was miscalculated, and it's now proposing to pay $70,864.90, which is one-seventh of the original charge, Bebinger reports.

According to Royer, the air ambulance company in a letter said Cunningham had to sign over the rights for Angel MedFlight to negotiate with CareFirst—or possibly be held liable if CareFirst wouldn't pay.

Bess said Angel MedFlight will not demand payment from Cunningham and is negotiating with the insurer (Bebinger, Kaiser Health News, 12/21/18; HR 302, accessed 1/3).

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