DENVER – While Denver7’s consumer investigations team was digging into a Denver couple’s surprise medical bill for a surprisingly short ambulance ride, we uncovered something called the “ambulance gap.”
In short, the ambulance gap is a loophole in federal legislation that went into effect last year called the No Surprises Act.
The law aims to reduce what’s called balance billing. Balance billing happens when the difference between what a medical provider charges and what insurance pays in an out-of-network treatment is passed on to the patient.
Ground ambulances, however, were excluded from the law, and therein lies the ambulance gap.
Lawmakers in Colorado addressed the gap with some protections at the state level. Those protections, though, are only for people who have insurance plans that are regulated in Colorado, according to Adam Fox, the deputy director of the Colorado Consumer Health Initiative.
Fox called the protections in Colorado “incomplete.”
“Many people who have larger employer plans, their plan may not be regulated in Colorado, and so they're not subject to the protections that we have,” he said. “This is something that I think a lot of consumers don't necessarily realize, until they run into one of these situations.”
Insurance cards for plans regulated in Colorado will have a “CO-DOI” label in the corner. If your card doesn’t have that label, your plan is regulated elsewhere – either at the federal level or in another state – and you are susceptible to the ambulance gap loophole.
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The case spotlighted by Denver7 was that of Alvin Gordy, who had a seizure at his doctor’s office on the Swedish Medical Center campus last July. He was taken by ambulance to an emergency room at the same hospital.
The surprise was the $1,900 bill that came in the mail from Northglenn Ambulance for that ride.
Since the Gordys’ insurance plan through Cigna isn’t regulated in Colorado, they were not protected from the ambulance bill.
What do I do if I’m stuck in the middle of the loophole?
Fox said there are steps you can take if you find yourself in this situation.
In some cases, you can appeal with the insurance company and get them to pay more to the ambulance company. In others, you can file a complaint depending on where the insurance plan is regulated, Fox said.
In the Gordys’ case, with Denver7’s help, Northglenn Ambulance lowered its charge and Cigna increased the amount it would cover. In the end, the Gordys’ bill was wiped out. Fox warned, though, that completely eliminating a bill is unlikely.
Fox also said people stuck in these situations can reach out to the Colorado Consumer Health Initiative’s Consumer Assistance Program to see if they can address it.
“We will work with consumers one on one to try to resolve issues like this,” he said.
At some levels, there is no ambulance gap. The federal government has already addressed the gap for people on Medicare and Medicaid, and is meeting with an advisory committee next month to address the gap entirely.
Fox said there is hope Colorado will address the ambulance gap at the state level. However, it likely won’t happen until next year’s legislative session.
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Coloradans hit with surprise ambulance bills not covered by new laws
