A affected person and air ambulance firm collectively sued Anthem on Wednesday, alleging the Indianapolis-based insurer wrongfully deemed a critically ailing affected person’s almost $240,000 flight to a hospital as “medically pointless.”
The lawsuit, filed within the U.S. District Courtroom for the Center District of Florida, arises from a protection denial confronted by an unnamed affected person, who suffered a coronary heart assault whereas on a cruise within the Dominican Republic in August 2019. The person was coated below an organization plan administered by Anthem by means of the Worker Retirement Earnings Safety Act. The affected person’s physician, who identified the person with myocardial infarction, insisted on medical evacuation to a level-one trauma heart within the U.S., the criticism mentioned.
The person left the Dominican Republic through Tampa, Florida-based Jet ICU, and flew to Broward Medical Middle in Ft. Lauderdale, Florida for care, in keeping with the criticism. Anthem, which operates Blue Cross and Blue Protect plans in 14 states, agreed to reimburse the affected person’s floor ambulance providers, however left the affected person on the hook for the $237,770 out-of-network air ambulance cost, which Jet ICU and the affected person allege violated its personal protection coverage.
Underneath Anthem’s certificates of protection, the insurer guarantees to cowl air ambulance providers when a person is transported for a medical emergency to a hospital, in keeping with the criticism. However in a letter denying the person protection in December 2020, Anthem contended: “There have been hospitals within the Dominican Republic that had been capable of present the care that you simply wanted.”
The criticism acknowledged that Anthem didn’t specify which native hospitals operated level-one trauma facilities that might have offered the care the person wanted. Legal professionals additionally questioned why Anthem paid for the affected person’s land ambulance journey in Florida if the person might have been handled at a hospital within the Dominican Republic.
“The truth that it did illustrates what’s at difficulty: [Anthem’s] arbitrary and capricious determination making to economize relatively than an precise medical necessity dedication,” the criticism mentioned.
By denying air ambulance protection, the person and Jet ICU alleged Anthem owes them for unpaid advantages below ERISA, and violated a Florida legislation that states insurers should reimburse out-of-network suppliers for emergency providers.
Anthem didn’t reply to an interview request.
The No Surprises Act is meant to guard sufferers from being balance-billed for top out-of-network prices, together with invoices that come from air ambulances, that are steadily rising in worth. The common worth of an air ambulance journey rose 27.6% from 2017 to $24,507 in 2020, a recent FAIR Health analysis found.
From 2014 to 2017, 77% of air ambulance transports of commercially insured sufferers had been designated as out-of-network, according to Milbank Quarterly. From 2016 to 2017, affected person payments averaged about $20,000 for these shock providers, the publication found.
However there are questions on how efficient the No Surprises Act will actually be at defending sufferers since air ambulance charges are, usually, so irrationally excessive because of fierce competitors amongst non-public fairness operators which have traditionally remained out-of-network, a recent Health Affairs article said. The rule stipulates that out-of-network arbitration between payers and suppliers will likely be based mostly on the median in-network price or beforehand contracted charges.
Some analysts additionally count on air ambulance firms to make up for any income misplaced below the legislation by charging larger in-network charges, which insurers will doubtless move on to customers within the type of pricier premiums. The Well being Affairs article referred to as for Congress to replace the value Medicare pays for air ambulance providers, after which use Medicare costs to find out industrial insurers out-of-network obligations.
“Arbitration can’t repair market failures, consolidation and unequal bargaining energy that characterize the air ambulance market,” Well being Affairs authors wrote.