EMS becomes Aetna in-network provider

June 10th, 2012 | Comments (0)

Aetna-insured patients who call 911 for an ambulance in Bensalem should no longer need to dread getting a bill for the portion of the transportation cost Aetna won’t cover.

In a deal that Aetna officials hope will mark the start of a trend, the health care company has signed a five-year contract with Bensalem Emergency Medical Services, in which the ambulance corps will essentially join Aetna’s list of in-network providers.

The contract sets the amount that the ambulance company will receive from Aetna whenever it takes an Aetna customer to the emergency room and eliminates the need for Bensalem EMS to bill the patient afterward.

“The predictability is great because Bensalem EMS knows what it’s going to be paid by Aetna and our members don’t have to worry [about being billed],” said Aetna spokesman Walt Cherniak.

Bensalem EMS approached Aetna with the proposal after the insurance company announced last summer that it was capping its ambulance company reimbursements at a rate equal to what the federal Medicare system provides, plus an additional 25 percent.

Thomas Topley, Bensalem EMS’ executive director, estimated that the change would have reduced Aetna’s reimbursement to the EMS squad by about $86,000 this year. “And we would have to bill the Aetna patients for the difference,” Topley said.

While the terms of the contract weren’t released, Topley said the new reimbursement rate would be less than 100 percent, but more than it would have received under the change Aetna announced last summer.

“We were able to meet the insurance company in the middle,” he said.

Bensalem EMS responds to almost 6,000 emergencies per year, mostly in Bensalem and Lower Southampton. Though the ambulance corps gets money from local taxes and receives grants from the state and federal government, fees for its services accounted for 68 percent of its revenue in 2006.

Most of the patients it serves have Medicare or Independence Blue Cross insurance. The rates from Medicare, a government program, aren’t negotiable. And Topley said Bensalem EMS approached Blue Cross two years ago with a similar proposal, but was unable to seal the deal.

Topley added that knowing exactly what Aetna will pay should help the ambulance company plan its annual budgets. The contract isn’t expected to impact response time or require the Bensalem EMS to take on non-emergency transportation calls for Aetna clients, he said.

Though the insurance company will reimburse Bensalem EMS at a higher rate than its standard Medicare plus 25 percent, Aetna said it expects to earn some goodwill with its investment. Cherniak said the deal would eliminate angry phone calls from customers to Aetna about why the insurance company did not cover more of the Bensalem EMS cost.

“There is a benefit to us as well — happier members and a better customer experience,” said Cherniak.

Most EMS providers do not belong to managed care networks. In fact, Cherniak said he didn’t think Aetna had any other contracts with ambulance companies in the region, but he added he believes this had been done in other parts of the country.

“We hope this is the first of others to come,” he said. “We hope this opens up the door to more deals where ambulance companies elect to pursue contract arrangements with Aetna.”

Cherniak said he didn’t believe the deal would make Aetna clients more likely to abuse the system by calling 911 for a Bensalem EMS ambulance when it isn’t absolutely necessary.

“That wasn’t part of the discussion,” he said.

Aetna provides health benefits for more than 850,000 members in Southeastern Pennsylvania.

John Anastasi can be reached at 215-949-4170 or janastasi@phillyBurbs.com.

Bucks County Courier Times