After Steve On Your Side contacted the insurance company, Anthem Blue Cross Blue Shield agreed to process the claim.
DENVER — When two parents were billed tens of thousands of dollars after their son had a medical emergency, their insurance company initially said they wouldn’t pay.
During the RSV outbreak in December 2022, Kelly and Chris Calero didn’t hesitate when their son Ethan started having trouble breathing. They took him to Southern Children’s Hospital in Highland Ranch.
His condition worsened overnight, and doctors told the family he needed to be transferred to Children’s Hospital’s main campus in Aurora, 34 miles away.
“When you see a lot of health care workers around you, you start to get really worried,” Kelly said. “That’s when, as a parent, you think, ‘Wow, this could go south really quickly.'” And that’s really scary. ”
Carreros and others said doctors told them it would be six hours before a suitable ground ambulance could reach the hospital. So doctors decided to send Ethan by helicopter air ambulance to Aurora. They said they really had no choice.
They flew him to Aurora and Ethan recovered.
Almost a year and a half after that ordeal, the Calero family was battling with their insurance company to cover a nearly $60,000 bill from ambulance provider Reach Air, until Steve on Your Side intervened.
“I got the bill and I thought, well, I’m going to calm down,” Kelly said. “We’re going to go through this whole process.”
She thought her insurance would cover the bill. Her husband, Chris, said she called her insurance company, Anthem Blue Cross Blue Shield, after her insurance claim was initially denied in February 2023. She said her attorney told her that she should be compensated for the ride and that she would begin an appeal.
In November, they received notice that their appeal had been denied.
“[The insurance company said] Waiting for ground transportation wasn’t that dangerous,” Chris said, recalling what was written in the rejection letter.
He said it was clear from medical records that Ethan was in severe distress and required transport. The family contacted the children’s hospital and said they received a letter stating medical necessity to submit in a second appeal.
This second appeal was rejected earlier this year.
“It just puts our whole life on hold,” Kelly said. “Right now we live in a rental, but we would like to buy a house. But we will have to wait until we know what our financial situation will be.”
Their denial is similar to the story of other air ambulance bill denials.
Last month, Steve on Your Side profiled a Castle Pines family whose daughter needed the same flight as Ethan Calero. Their insurance company, Anthem Blue Cross Blue Shield, also denied their $60,000 claim until Steve On Your Side asked about it.
KFF Health News reports that in California, a 3-month-old baby infected with respiratory syncytial virus was transported 100 meters from the ground despite the insurance company’s claim that it could have been carried by ground ambulance. The family was denied a $97,000 air ambulance bill that would have required him to be taken to another hospital miles away. . The child’s doctor ordered a helicopter.
KFF Health News reporter Molly Castle Work pointed to a February letter from the president of the National Association of Emergency Medicine Physicians (NAEMSP) to several Cabinet members, including Health and Human Services Secretary Xavier Becerra.
The industry group said in a letter that it had noticed a wave of insurers denying air ambulance claims since the No Surprises Act came into effect in 2022. The law prohibits health care providers from billing out-of-network patients for balances after an insurance company has paid a claim.
But Castle Wark said that under the law, insurance companies can deny claims if they determine the services are not medically necessary.
“Our understanding is that if you deny an application on the basis that the plan is medically unnecessary, you are essentially circumventing the law,” Castle Wark said. Her report on the California bill.
Insurance companies, including Anthem, are driving down the cost of these tickets in the first place. Mr Castle Wark said the price increase was related to private equity gobbling up air ambulance companies. He also said the anti-surprise law is creating an environment for price increases.
“If there’s a requirement between the insurance company and the ambulance, or they can’t agree on the amount of compensation, they basically have a chance to fight, and then it goes into the federal appeals process,” Castle Work said. There is a possibility.” “What we’re hearing is that ambulances almost always win in the federal appeals process. So they basically feel permission to keep raising prices.”
NAEMSP is petitioning the federal government to change the definition of medical necessity, essentially requiring insurance companies to cover claims if a hospital’s licensed physician determines it is medically necessary. is obligatory.
When Steve On Your Side asked Anthem about Ethan Calero’s bill, the insurance company said the air ambulance company had not provided Anthem with all the medical information he needed.
“The application was approved after receiving detailed information regarding this member’s medical condition from Children’s Hospital Colorado,” Anthem said in a statement.
A few days after Steve On Your Side contacted Anthem, the company called Chris Calero to let him know it would process the claim. The battle, which lasted about a year and a half, has come to an end.
“I feel like we can have some peace,” Kelly Calero said. “Our kids will be healthy. And we’ll just move on.”
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