AMBULANCE BILLING FEES

Transcription

1 AMBULANCE BILLING FEES At roughly 75% of Big Sky Fire Department responses, Emergency Medical Services and Ambulance Transports take up a large portion of the department s operating budget. While some of this is funded by property taxes and resort tax contributions, the system is designed so that those who use BSFD EMS/Ambulance Transports pay fees to help offset passing additional costs to taxpayers. At first glance, BSFD s fee structure is higher than some people would expect. One must take into account Big Sky s higher operating costs due to remote operating location, distance from a receiving hospital and higher cost of living while evaluating the fees involved to provide professional level Advanced Life Support and Basic Life Support emergency medical care. Drug charges reflect actual cost to BSFD based upon their typical dose while all other charges reflect average operational costs. Effective January 1, 2013 RATE AND SUPPLY CHARGES BLS EMERGENCY TRANSPORT $ ALS EMERGENCY TRANSPORT $ 1, MILEAGE $ BLS ROUTINE SUPPLIES $ ALS ROUTINE SUPPLIES $ IV SUPPLIES $ OXYGEN $ INTUBATION SUPPLIES $ EXTRA ATTENDANT $ WAITING TIME $ BLS DEFIBRILLATION $ ALS DEFIBRILLATION $ EKG SUPPLIES $ 5.75 DRUG CHARGES FENTANYL $0.81 ASPIRIN, 162MG $0.15 AMIODARONE $15.50 ATROPINE BRISTO 1MG/10 $4.80 EPINEPHRINE 1:1000 Pen $ DEXTROSE 50% 50ML $10.80 EPINEPHRINE 1:10,000 B $5.70 ORAL GLUCOSE/BLS $4.80 EPINEPHRINE 1:1000 $1.20 SODIUM BICARB 8.4% 50ML $8.85 CALCIUM CHLORIDE 10% $9.80 LIDOCAINE 100MG BRISTO $8.40 LASIX/FUROSEMIDE 40mg $1 NITROGLYCERIN.4MG spray $3.90 NARCAN 2 mg $20.65 LIDOCAINE 100mg IN D5W-DRIP $13.00 MORPHINE-PERSERV.FREE10mg $0.53 VALIUM/DIAZEPAM 5mg VERSED 5mg $0.53 ONDANSETRON 4mg IV $5.09 ONDANSETRON 4mg Oral Tab $0.26 PHENERGAN (PROMETHAZINE) $2.79 ALBUTEROL.083% $0.46 PROVENTIL $0.15 BENADRYL 50MG/1ML $2.09 BENADRYL 50MG Oral Tab $0.40 DOPAMINE HCL 400 mg $12.80 PITOCIN 10 UNITS $8.70 ADENOCARD 6MG $27.85 ADENOCARD 12MG $49.95 GLUCAGON INJECTION 1mg $ HALDOL 5mg $6.95 MAGNESIUM SULFATE $3.78

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4 Board of Trustees Policy No Big Sky Fire Department Ambulance Billing Hardship Policy PURPOSE: To establish a policy that may allow the modification of ambulance transport fees based upon the request of patients who are suffering a financial hardship. It is important to note that no ill or injured person will ever be denied necessary medical transport service due to either their inability to pay or a lack of insurance. SCOPE: This policy allows the Fire Chief to make modifications to or write off ambulance billings to patients who make formal application for relief due to their suffering from a financial hardship. ELIGIBILITY: A financial hardship will be established by utilizing the most recent available United States Department of Health and Human Services (DHHS) Poverty Guidelines. Patients who are at or below the Poverty Guidelines automatically may qualify for a write off of their ambulance bill. Patients who are % of the Poverty Guidelines may qualify for a review of their request by the Fire Chief, who has the option to: o Set up a long term payment plan for the full bill o Modify the amount of billing to ease the burden upon the patient o Write off the ambulance bill Patients who are % of the Poverty Guidelines may qualify for a review of their request by the fire chief, who has the option to: o Set up a long term payment plan for the full bill o Modify the amount of billing to ease the burden upon the patient Required Documentation (a minimum of two forms of the following documentation is required): o Most recent W-2 withholding statement, or o Unemployment check stubs for past 90 days, or o Paycheck stubs for the past 90 days for all persons employed in the home, or o Income tax return (most recent signed) o Any other information you wish to provide that will help in our decision making process. NOTE: Each resident as defined above may request one (1) hardship modification/write off per consecutive twelve (12) month period. United States Department of Health and Human Services 2012 Poverty Guidelines for the 48 Contiguous States and the District of Columbia

5 Persons in family/household Poverty guideline 1 $11, , , , , , , ,890 For families/households with more than 8 persons, add $3,960 for each additional person. NOTE: A patient injured while involved in the commission of a felony criminal activity is not eligible for a modification or write off. REQUEST FOR MODIFICATION PROCEDURES: 1. No one will ever be denied necessary medical transport service due to either their inability to pay or a lack of insurance. 2. The Fire Chief will address cases of financial hardship on an individual basis. 3. Patients who are unable to pay their co-pays, deductibles, or who are uninsured, unemployed, homeless, or for other reasons unable to make payments may request a financial hardship review of their transport charge. Patients, or their designee, shall complete the Big Sky Fire Department Ambulance Billing Hardship Application Form. The form is available on the Big Sky Fire Department website at can also be requested by calling BSFD at or by coming into BSFD Station 1 during normal business hours. Station 1 located in Westfork Meadows at 650 Rainbow Trout Run, Big Sky, MT. This form is also available from our assigned 3 rd party billing company Sole Stone Reimbursement at This fee modification application will be forwarded to the Fire Chief, who will make a final decision that will be noted on the form. The Fire Chief or his/her designee may waive all charges, reduce the charges, establish a payment plan or deny the request. All final resolutions will be noted on the form.

6 BIG SKY FIRE DEPARTMENT AMBULANCE BILLING HARDSHIP APPLICATION FORM This hardship application must be submitted for each ambulance transport fee modification request. Applicant Name SSN Applicant Address Contact Phone Number Date of EMS Transport I am requesting: My ambulance fee be waived My ambulance fee be reduced Establishment of a payment plan that better suits my ability to pay Monthly Household Gross Income: Number of dependents living in household: Attached documentation (a minimum of two forms of the following documentation is required): Most recent W-2 withholding statement Unemployment check stubs for past 90 days Paycheck stubs for the past 90 days for all persons employed in the home Income tax return (most recent signed) Any other information you wish to provide that will help in our decision making process Responsible Party (if different from applicant) Name: Relationship: Address (if different from applicant): Contact Phone Number In your own words explain why you are requesting a Hardship Waiver:

7 Attach additional sheets/information if necessary. I do hereby request that I, as either the applicant, or the party who is financially responsible for the applicant, be considered for a reduction in the payment responsibilities as they relate to this EMS transport service fee. By signing this form I certify that I have no insurance that can be billed for this charge. I declare that all of the information contained in this document and the attachments are true and accurate. Furthermore, I understand that I may be held liable for any false statements pertaining to this waiver request. I hereby agree to notify the Big Sky Fire Department of any change in the financial status of the applicant or the responsible party that may affect the ability to pay the Ambulance Transport Fee(s). Signature: Date: Printed Name: For questions regarding the hardship waiver process call or via to afischer@bigskyfire.org Hand-deliver or mail this application and all attachments to: Big Sky Fire Department PO Box Rainbow Trout Run Big Sky, Montana Big Sky Fire Department Administrative Use Only Incident #: Date of transport: Date request received: Claim: (circle) Approved Denied Reason: Date Billing Company Notified: Fire Chief Approval Signature: