Denial of ambulance reimbursement:: Can reviewers determine what is an emergency?

Abstract

Objective Use of ambulances for nonemergency and routine transportation is thought to be a serious and growing problem. Third-party payers frequently refuse payment when ambulance use is deemed inappropriate. The authors attempted to determine whether cases in which ambulance transport was denied were done appropriately. Methods Consecutive ambulance run forms of transports in which payment was denied by the state Medicaid carriers and corresponding emergency department (ED) charts were reviewed. Medical risk was evaluated by using the Evaluation and Management (E&M) Level of Care for the ED visit. Appropriateness of ambulance transport was evaluated by extracting the final diagnosis and the most serious written (and worked up) diagnosis in the differential. If either diagnosis could benefit from treatment in an ambulance or by rapid transport to a hospital, the transport was defined as appropriate. Results A total of 146 run forms and 104 corresponding charts were evaluated. Ambulance transport was appropriate in 63 (61%; 95% confidence interval, 51%–70%). Risk was minimal for two transports, low for two, moderate for 62, and high for 38 cases. Final diagnoses included several life-threatening ones. Conclusion In this population of patients for whom payment of their ambulance bill was denied, a high percentage of corresponding ED visits were for potentially serious medical problems.