Do we have a responsibility to share potential fees with patients?

MMiz

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At least once a year I hear from people about how absolutely shocked they are at the cost of an EMS transport.

Why aren't we advising patients of the costs prior to transport?

As an EMT I was always quick to say that I didn't know about billing, because I didn't know much beyond anecdotes from partners.

Surely the medical billing department has a document that outlines costs for transport, mileage, and different treatments.

By not sharing the information are we contributors to the huge medical debt crisis?
 

ffemt8978

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I'd say there are way too many variables that change fairly often for EMS to be giving financial information to patients.

Each insurance company is different, and Medicare/Medicade is a beast of it's own.

I can almost see EMS providing this info being more detrimental to the patient because we'd be providing inaccurate info to the patient which they would use to make decisions about their treatment and care. That might even expose EMS to some legal liability in some areas.
 

DesertMedic66

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Exactly as already said, there are way too many variabilities to be able to give the patient an exact number.

Sure we could give them what we charge but how much their insurance will actually cover, how much of a copay they will have, how much their deductible will be, or what their out of pocket cost will end up being will vary greatly.
 

Tigger

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Not much changes in CMS rates which set the standard for much of private insurance. Most agencies are not routinely changing their costs substantially on a routine basis either. What does change is what private insurers are willing to pay off the rates. Being that this is patient responsibility, it’s huge challeng to know what the patient’s share would be, but I hope that everyone knows approximately what they’re company is billing out on an a BLS and ALS transport.
 

CCCSD

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“Oxygen is $50 a liter, so....he’s short of breath...how much do you love him?”
 
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MMiz

MMiz

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Come on, it can't be rocket science. I searched and it doesn't look like the Medicare rates have changed too significantly in a decade.

Quite a few cities even list their fees.

What about a document that lists the cash prices for:
  • BLS call base price/mile
  • ALS call base price/mile
  • Common treatment price ranges: oxygen, IV EKG, immobilization, medications, etc.
Just like the HIPAA form and insurance billing form, it's a patient's choice if they want to sign. At least they have the information.
 

Carlos Danger

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This is a great question.

Overall, one of the biggest problems in our very complicated and troubled healthcare system is a lack of cost transparency. Individuals make much more rational (and most often conservative) choices when faced with known costs, and they tend to over-consume services when the costs are not transparent. This, of course, is why a lack of transparency is codified in law in many states. But that is a different conversation....

This issue is one of the reasons why I left HEMS after 12 years.

Disclaimer: All three HEMS companies I worked for were nonprofits who supposedly did not pursue folks who said they could not pay the massive bills they were sent. I would not have worked for a company with a different policy,

However, over that 12 years I still flew a LOT of patients whose outcomes would clearly have been the same if they'd gone by ground. And even if the patients didn't see that cost directly, it was still paid somehow, by someone. Jet fuel and pilots ain't cheap. Think about what that means.

Massive charges which financially ruin (some) people for the rest of their lives are absolutely unconscionable - especially when they were not medically necessary.

So my answer to the question is YES. I think any ethically reasonable consent has to include a consideration of the cost of treatment. I think this is true in any setting for any service, but becomes more important the more expensive the treatment is.
 

CCCSD

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You would be asking crews to get into arguments with family about costs during a call. If you misquoted a rate, can they sue for recovery? Is there a cash savings? Etc, etc, etc.

Back in The Day, we used to do wallet biopsies...
 
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MMiz

MMiz

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@Carlos Danger It was HEMS that got me thinking about this question. A friend had a family member flown to a hospital after a bicycle accident in a semi-remote area, and the HEMS bill was unbelievable.

@CCCSD Why does it have to be an argument? When I go to the dentist I ask the cost up front. Sedation and nitrous oxide were out of my budget for wisdom tooth removal so I opted for local.

Informed consent still applies, and we can continue to do our best to inform and persuade refusals.

I haven't worked in EMS in years, but I wonder how many non-emergent BLS patients would have driven to the hospital or taken an Uber if they knew the actual cost of service.
 

CCCSD

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When you go to the dentist, it’s not an emergency that necessitated calling 911.
Why on earth would you dump this on the crew? Why not just have a recording on the 911 line that states rates, press 1 for Y, 2 for N, then pass on to the operator?

I worked for companies who charged at the scene. We had to carry receipt books and calculate all fees and mileage, plus provide patient care while getting railed at for charging for services. Thank God the seventies are over.
 

cruiseforever

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"I've been told we are expensive." is my line to pt.'s that ask. Our system does not want us to get into the billing talk with pts..
 

DrParasite

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I don't know enough about billing to explain the costs. I used to know the criteria between BLS, ALS1 and ALS2, but that's mostly long forgotten. Factor in how insurance companies have different pay rates, and if they have medicare or Medicaid, or are uninsured, homeless, or just don't want to give me their real name... there are a lot of variables, and I don't want a patient or family to be able to say "your ambulance driver told us insurance would cover this, but they didn't, so now someone else needs to pay for it" or "the ambulance driver said it would cost $1000 + millage, so we decided to take the patient to the ER ourselves, and he died... so now we are suing you for negligence"

I bet if you asked most providers (doctors, dentists, nurses, RTs, etc) how much a procedure will cost a patient, they wouldn't be able to tell you. They might know how much they charge, but insurance can change how much the patient pays. Not only that, but the healthcare pros hire a billing person / officer clerk that keeps track of stuff like this.
@CCCSD Why does it have to be an argument? When I go to the dentist I ask the cost up front. Sedation and nitrous oxide were out of my budget for wisdom tooth removal so I opted for local.
did the dentist actually tell you that? or did you have a sit down with the billing person, who explained the costs, and what would be covered by insurance? and then you decided what you wanted to get, based on the numbers provided?

BTW, I used to work for a hospital based EMS system, and it was the ER's policy not to ask for insurance information until you were admitted or discharged. I don't think the medical staff ever covered the cost of anything.
 

E tank

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The time to ask/tell about fees/billing isn't when you need the services. If folks are sincerely concerned/interested they should be having the conversation with billing/financial depts during business hours over the phone. Additionally there are stupid cheap "memberships" that systems may offer if they're really worried.

It's in the same category as someone I know asking me what I think of a particular surgeon the day before they're scheduled for surgery...kinda too late for a meaningful answer.
 
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MMiz

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I feel like a lot of the responses I'm seeing go along the lines of talking about costs prior to treatment isn't the norm or isn't part of a provider's knowledge / typical customs. This lack of transparency is part of the problem with healthcare in America.

@DrParasite I went to the dentist with horrible jaw pain, he showed me the horrible condition of my wisdom teeth, and handed me a clipboard with typical fees for removal. Shocked at the high cost, and knowing my dental insurance didn't cover much, I only had the one causing the most pain removed until my dental insurance rolled over the following year. In retrospect I wish I spent the $100 extra for the nitrous oxide.

EMS transport costs in the United States are substantial, 100+ million Americans are struggling with medical debt. What, if anything, can we do as an institution to help?
 

CCCSD

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It isn’t the job of every EMT to know the cost of each item of care, since every single one has a variable. How much time should they spend at the scene haggling before they touch the patient? Lawsuit waiting to happen.

They can always AMA and transport in their POV if they don’t want to pay...
 

E tank

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I feel like a lot of the responses I'm seeing go along the lines of talking about costs prior to treatment isn't the norm or isn't part of a provider's knowledge / typical customs. This lack of transparency is part of the problem with healthcare in America.

@DrParasite I went to the dentist with horrible jaw pain, he showed me the horrible condition of my wisdom teeth, and handed me a clipboard with typical fees for removal. Shocked at the high cost, and knowing my dental insurance didn't cover much, I only had the one causing the most pain removed until my dental insurance rolled over the following year. In retrospect I wish I spent the $100 extra for the nitrous oxide.

EMS transport costs in the United States are substantial, 100+ million Americans are struggling with medical debt. What, if anything, can we do as an institution to help?
The American Hospital Association and the US Congress haven't come up with anything they can agree on, so there won't be a solution here. At the end of the day consumers have a choice...accept the fees, shop around, or pay on time like folks do with everything else in their lives.

The Atlantic has had a couple of good articles about this problem over the years...this isn't the best one, but it gives an idea of the scope of the problem:

 

Carlos Danger

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It isn’t the job of every EMT to know the cost of each item of care, since every single one has a variable. How much time should they spend at the scene haggling before they touch the patient? Lawsuit waiting to happen.

They can always AMA and transport in their POV if they don’t want to pay...
How is not touching the patient until the've consented to care a "lawsuit waiting to happen"? And how can the patient make a reasonable and informed decision whether to "AMA and transport in their own POV" when they have no idea what the transport is going to cost, and what the potential benefits of EMS transport are?

It isn't as if people only call 911 for life threatening situations. In case you've never noticed, very few EMS responses are true emergencies. So it's not like every call is some time-critical super dramatic life-or-limb emergency where there's simply no time to discuss risks / benefits / costs of EMS transport vs. other options. People can and should be educated and given options to whatever extent possible, just like everywhere else in medicine. That should be considered part of obtaining informed consent.

I would not expect an EMS crew to ever spend any time at all "haggling" over the cost of the transport or the care that the crew deems appropriate, or to provide an itemized estimate of the cost of the transport beforehand. However, if asked, it seems pretty reasonable that the crew should be able to say "Ma'm, the base cost of a BLS transport is $1000 plus $X per mile, plus supplies. If we have to start an IV or provide other advanced interventions in order to manage your condition or treat pain, then it becomes an ALS transport, and the cost increases. That should give you some idea, but there is no way I can tell you exactly what your transport will cost you." Then the crew can go down one of two roads and either say "We are very concerned about your chest pain and low blood pressure and we really think it is in your best interest to come with us and worry about the cost later", or "we'll gladly transport you in the ambulance, but it doesn't appear as though your sprained wrist will benefit from EMS transport. So if you are concerned about the cost of transport, you can go by POV to the ED or an urgent care, or even your regular doctor's office". Is that really that hard?

The American Hospital Association and the US Congress haven't come up with anything they can agree on, so there won't be a solution here. At the end of the day consumers have a choice...accept the fees, shop around, or pay on time like folks do with everything else in their lives.
If it were that easy, then the issue wouldn't come up often as it does. Most people with insurance are confined to the use of one or perhaps two health systems for their care if they want to use their insurance meaning shopping around isn't an option at all. Also, many people have found that hospitals can't or won't give you an answer when you call to inquire what your lap cholecystectomy (for instance) is going to cost, or even what your share of the cost will be after your insurance pays its part. Part of that is of course because the cost of surgical procedures is heavily dependent on the amount of time that the procedure takes, but many times you can't even get a rough idea or an average.
 

DrParasite

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One other thing to consider... a $1500 ambulance bill is nothing compared to an 80,000 ER bill with hospital admission. A $500 ambulance bill is minor compared to a $10,000 ER bill for a simple discharge. And these costs don't include the cost for the ER doc, xray/radiolgy, or other non-ER services.

I know many of these numbers are inaccurate, because I don't know the actual costs, but I do think that the ambulance bill is a drop in the bucket compared to the entire bill for the "emergency service" from calling 911 to discharge from the hospital.
 

CCCSD

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How is not touching the patient until the've consented to care a "lawsuit waiting to happen"? And how can the patient make a reasonable and informed decision whether to "AMA and transport in their own POV" when they have no idea what the transport is going to cost, and what the potential benefits of EMS transport are?

It isn't as if people only call 911 for life threatening situations. In case you've never noticed, very few EMS responses are true emergencies. So it's not like every call is some time-critical super dramatic life-or-limb emergency where there's simply no time to discuss risks / benefits / costs of EMS transport vs. other options. People can and should be educated and given options to whatever extent possible, just like everywhere else in medicine. That should be considered part of obtaining informed consent.

I would not expect an EMS crew to ever spend any time at all "haggling" over the cost of the transport or the care that the crew deems appropriate, or to provide an itemized estimate of the cost of the transport beforehand. However, if asked, it seems pretty reasonable that the crew should be able to say "Ma'm, the base cost of a BLS transport is $1000 plus $X per mile, plus supplies. If we have to start an IV or provide other advanced interventions in order to manage your condition or treat pain, then it becomes an ALS transport, and the cost increases. That should give you some idea, but there is no way I can tell you exactly what your transport will cost you." Then the crew can go down one of two roads and either say "We are very concerned about your chest pain and low blood pressure and we really think it is in your best interest to come with us and worry about the cost later", or "we'll gladly transport you in the ambulance, but it doesn't appear as though your sprained wrist will benefit from EMS transport. So if you are concerned about the cost of transport, you can go by POV to the ED or an urgent care, or even your regular doctor's office". Is that really that hard?


If it were that easy, then the issue wouldn't come up often as it does. Most people with insurance are confined to the use of one or perhaps two health systems for their care if they want to use their insurance meaning shopping around isn't an option at all. Also, many people have found that hospitals can't or won't give you an answer when you call to inquire what your lap cholecystectomy (for instance) is going to cost, or even what your share of the cost will be after your insurance pays its part. Part of that is of course because the cost of surgical procedures is heavily dependent on the amount of time that the procedure takes, but many times you can't even get a rough idea or an average.
Yes. If the crew is wrong, here come the lawsuits, in case you haven’t noticed, Ameridians will sue at the drop of a hat.
There is no need to dump all this on a crew. Non emergent calls to a company can be dealt with by a QC person handed off from dispatch.

Again. What does this have to do with field care? What if it’s a FD handoff and since taxes pay for FD services, then you tell them it’s $$$, and the rightfully demand the “free ride” from FD, who refuses, what then? The crew has to step in the middle of it? Please. Stop trying to foist ever single issue onto the workers.

Fees have ZERO to do with informed consent. Wil we then allow the patient to dictate what care they get to save money? If so, you just made a perfect argument for BLS only EMS. Go cheap. No harm in that, eh?
 

Carlos Danger

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Fees have ZERO to do with informed consent. Wil we then allow the patient to dictate what care they get to save money? If so, you just made a perfect argument for BLS only EMS. Go cheap. No harm in that, eh?
Sorry to break it to you, but cost is very much a part of informed consent. We already "allow" people to make medical decisions all the time based at least partly on cost.
 

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