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Ben Millheim fractured his skull after falling about 13 feet during a camping trip with family and friends in the fall of 2016.

After racing into town to get a cell signal, the family finally reached an ambulance by phone. Upon seeing the injury, the family was told the unconscious boy, who was bleeding from his ears and having seizures, would need to be airlifted to a hospital in St. Louis, Mo. more than 100 miles north by car.

Fortunately, Ben survived.

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"Watch me do a back flip," said Ben Millheim, 8, as he joyfully jumps on the trampoline in his backyard on Thursday, March 1, 2018, in South St. Louis County. Millheim, was airlifted from rural Missouri to a local children's hospital after fracturing his skull during a camping trip with friends and family in 2016. The young boy survived without any medical issues but his family owes more than $32,000 for the 83-mile ride.Photo by Laurie Skrivan, lskrivan@post-dispatch.com

But the family has been caught in the middle of a billing practice that can have devastating financial consequences for patients. What the family didn’t know at the time of the accident was that the air ambulance was out of network. Now they are on the hook for more than $32,000.

They’ve exhausted all their appeals with Anthem Blue Cross Blue Shield, the insurance company that covered the south St. Louis County family of five at the time of the accident. The family has tried to get the insurance company to pay a larger share of the bill, but Anthem has refused.

“Obviously, no one plans for a situation like this, and hopes it never happens, but the whole reason for having insurance is to cover this type of stuff,” Dan Millheim, Ben’s father, said.

Balance billing

Anthem is one of the state’s largest insurers. Millheim purchased the family coverage through HealthCare.gov, an online marketplace for consumers to purchase insurance.

The total amount billed for the transport was $44,232. Anthem paid Air Evac Lifeteam $11,787, leaving the Millheims with a bill of $32,445, according to documents provided by the Millheims.

“My jaw hit the floor,” Millheim said upon seeing how much they owed.

The practice is known as balance billing. It’s when out-of-network providers stick patients with the difference between what the provider billed for and what the insurance carrier paid the provider.

To be considered in-network means providers and the insurance company have agreed to certain rates for services.

Some states have passed legislation to limit balance billing, but Missouri has not, according to a report from the Commonwealth Fund, a private foundation that focuses on health care issues.

And state legislation may not have an impact in regulating this corner of the health care industry due to how air carriers, including air ambulances, are regulated at the federal level.

There are no federal protections that ban this billing practice, according to the Commonwealth Fund report.

“Patients are exposed to enormous financial risks if they need an air ambulance transport,” said Erin C. Fuse Brown, a health law expert at Georgia State University. “There is no way to tell whether the ambulance is in-network, no requirement that insurers have air ambulances within their network, and no way to anticipate or avoid a devastating balance bill if the air ambulance turns out to be out of network.”

In the Millheims’ situation, the insurance company and the air ambulance provider are pointing fingers at each other.

The insurance company has balked at the prices being charged by Air Evac, while Air Evac claims Anthem is underpaying for the service.

“I will stand behind my charges,” said Seth Myers, president of O’Fallon-based Air Evac. “They’re the bad actor,” he said of Anthem. He said Anthem suddenly stopped paying what he called “a reasonable amount” just a few years ago.

“I want to take the patient out of the middle of this problem,” Myers said.

The majority of patients his company transports have government-sponsored health plans such as Medicaid or Medicare, or are uninsured. Because of this, he said the company relies more heavily on private insurance to make up for what it doesn’t earn on Medicaid or Medicare patients.

Patients with Medicare and Medicaid are protected from receiving a surprise bill like this that amounts to the difference between what the insurer pays and what the out-of-network provider charges.

“It’s the same thing that’s happening all across the health care industry,” said Shelly Schneider, a spokeswoman for the company.

The company encourages consumers to buy annual memberships, which Schneider says will protect them from being stuck with the difference between what their insurance company pays and the cost of the transport. Annual memberships cost $65 per household, Schneider said. However, there’s a chance another firm could pick up an Air Evac member after an accident, and the membership deal would not apply.

Air Evac and three other major firms are included in the membership, which has more than 320 air medical bases across 38 states.

Together, there are currently 3 million consumers enrolled in the membership program.

The membership is not considered insurance and is not regulated by the Department of Insurance.

Air Evac Lifeteam is part of Texas-based Air Medical Group Holdings, which claims to be the largest independent provider of emergency air medical services. Air Medical Group Holdings is owned by New York-based investment firm, KKR.

“If the patient cannot afford the balance, our patient accounts will work with them to set up a monthly plan,” Schneider said.

Critics say there is no incentive for air ambulances such as Air Evac to agree to pricing terms with insurance companies to become an in-network provider.

However, Air Evac said Missouri’s other largest insurers — Blue Cross Blue Shield of Kansas City and UnitedHealthcare — pay a reasonable rate even though they’re out of network.

“The insurance company has an obligation that protects people in emergencies, and that means they should have adequate coverage of ground ambulance and air ambulance,” said Sidney Watson, a health law professor at St. Louis University.

Because Anthem and Air Evac can’t come to pricing terms, families such as the Millheims are left in the middle.

“He was unconscious, having seizures and bleeding out of his ears. For the insurance company to turn around and pass the bill on to us seems incredibly cruel and outlandish,” Dan Millheim said.

The state insurance department received 15 complaints against insurers on the issue of air ambulances last year. The department has investigated 53 complaints since 2013.

Meanwhile, SSM Health Cardinal Glennon Children’s Hospital, where Ben was taken, said it receives about 700 patients annually via air ambulances.

Regulating price

A law that was meant to spur competition in the airline industry has caused issues for states and plaintiffs when it comes to addressing the price of air ambulances.

The Airline Deregulation Act of 1978 bans any state from regulating the price or routes of air carriers. Air ambulances are considered to be air carriers, so when consumers have sued air ambulances, claiming a violation of state consumer protection laws, their cases often are dismissed.

In one case in Oklahoma, Judge David L. Russell dismissed a 2017 lawsuit against Air Evac, but in his order he said he sympathized with the plaintiffs that “these rates are unfair.”

In 2014, the median price for an air transport was $30,000. Just four years before, a transport priced at $30,000 was in the 95th percentile — “meaning 95 percent of all prices charged were below that amount — according to both Medicare and private health insurance data,” said a 2017 report by the U.S. Government Accountability Office.

In a January memo, the National Association of Insurance Commissioners said that over the past decade, many states have reported issues with air ambulances no longer affiliated with a hospital and some that refuse to contract with insurers. The trend has resulted in significant out-of-network bills for consumers, the report said.

“Federal legislative action is necessary to give states the authority to address this issue,” the brief said.

Missouri’s senators, Republican Roy Blunt and Democrat Claire McCaskill, were critical of the practice.

“No family should be left financially devastated by a medical emergency,” Blunt said in an email. He said he’s reviewing the issue and legislation that has been introduced on the issue.

“It breaks my heart that a family that’s done everything right — they have insurance, work hard, pay their bills — yet when the unthinkable happens and they need emergency care for a traumatic injury, their insurance covers just a fraction of the costs and they’re stuck paying the bill,” McCaskill said in an email. She said she is committed to fighting the issue.

The 2017 GAO report said it’s unclear how widespread the problem is, so improvements need to be made in collecting consumer complaints. The Department of Transportation has authority to investigate unfair practices in the airline industry but said consumers may not know that air ambulances are included in its oversight.

It’s been a more than a year since Ben’s accident. Fortunately, he’s a healthy 8-year-old boy who has had no lasting effects from his injuries.

He’s now in second grade and likes to skateboard and jump on his backyard trampoline. He thinks he wants to be a teacher when he grows up.

“At the end of the day, for me, the important thing is that my son is OK. I can’t afford it, but I can do a payment plan until I’m 200,” Millheim said. “Money is never more important than family. We’ll figure it out one way or another.”

Reporter Samantha Liss is focusing on medical costs. Do you have a bill that you consider excessive? You can contact her at sliss@post-dispatch.com for possible use in a future story. 

Samantha Liss • 314-340-8017

@samanthann on Twitter

sliss@post-dispatch.com

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