Today’s Q&A on is about Medicare’s rules regarding payment for ambulance services

Question:  My brother has Medicare as his primary insurer and Plan F as his Secondary Supplement (Mutual of Omaha).  He has congestive heart failure, requires oxygen, kidney failure, problems with vision, diabetes and is unable to walk.  He is confined to his home.  His wife provides his care. He is unable to ride in a car.  He cannot walk or support himself to get in and out of car and he needs supervision and oxygen when making a trip. He also requires a bariatric stretcher due to his weight.  He has dialysis three days a week and Medicare provides ambulance service to and from the facility due to medical necessity.  If he has any type of surgery, Medicare provides an ambulance.  When he goes for a follow up visit after surgery or when he has an appointment with a specialist, the ambulance service states that Medicare will not pay under any circumstances.  I have called Medicare and received conflicting answers to this question.  I need clarification.  I have also received conflicting answers from different ambulance services.  He lives in a small town and there is only one ambulance service available with a bariatric stretcher.  How does a person who cannot ride in a car get ambulance service for follow up appointments after surgery and to specialist’s offices when needed?  He has had two cataracts removed and needs to see an ophthalmologist that is about 43 miles from his home.  What are our options?  He is unable to pay for this service himself and from what I read on the Medicare site, the ambulance trip should be covered if medically necessary.  Any help would be appreciated.

Answer:  The rules regarding Medicare payment for ambulance services can be complex. Medicare will pay for the emergency transportation to a hospital or a skilled nursing facility when other transportation could endanger your health.  Medicare will also cover ambulance services in certain specific circumstances, one of which is if you have End-Stage Renal Disease, need dialysis, and need ambulance transportation to or from a dialysis facility because other transportation could endanger your health.  That is why your brother receives the services when going for dialysis.  

In addition, in some cases, non-emergency ambulance transportation may be provided when you need ambulance transportation to diagnose or treat your health condition and use of any other transportation method could endanger your health.  Medicare may cover limited non-emergency ambulance transportation if you have a statement from your doctor stating that ambulance transportation is necessary due to your medical condition. This would seem to apply to your brother cannot ride in a car and needs an ambulance with a bariatric stretcher.  The ambulance company needs to fully document why your brother needs the ambulance transportation.  If it fails to properly document it, Medicare will deny coverage.  If this happens, contact the doctor who treated you or the discharge social worker at the hospital to get more information about your need for ambulance transportation.  Then have the ambulance company resubmit the bill to Medicare. If you or anyone else needs more information regarding what Medicare covers regarding ambulance services, Medicare has a publication on the subject at Good luck.

James C. Siebert, Esq.
The Law Office of James C. Siebert & Associates
Arlington Heights, IL  60004
Member of the national ElderCare Matters Alliance, Illinois chapter


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