The previous article in the Borrego Sun, April 15 issue, (Page 15) on emergency airlift evacuation which attempted to explain costs and comparisons of the two services available in Borrego Springs led to one conclusion: Digging further into the weeds, legal, insurance terminology, and explanations, details of costs and financial consequences of emergency air evacuation only leads to more questions.

Leaving out many of the explanations for the costs and other problems with the industry; and other complications that allow insurance companies to wiggle out of payments, here are the facts.

There are two emergency air evacuation companies servicing Borrego Springs and the 92004-zip code: Mercy Air, which is an affiliate of the larger corporate AirMethods; and REACH, the local arm of the AirMedCare network. Mercy Air is not affiliated with San Diego’s Mercy Hospital.

Emergency air lift to a hospital could cost $60,000 to $125,000. The average cost is $25,000 for air travel and $450 for emergency ground transport. Ground paramedic transport to the Mercy Air base adjacent to the Borrego Springs clinic, is not covered by either the Mercy Air agreement with BVEF fund or the REACH membership and can cost thousands, and may not be covered by private or government health plans. It’s complicated too.

“Medical air transport costs vary greatly, and price alone is not a quality indicator. Costs are seldom covered by insurance and many services require full payment in advance,” according to the Mayo Clinic.

Private health, credit card, or other travel coverage, as well as government (Medicare, Medicaid, Cal-Med, or employee insurance policies may only contribute a limited amount, depending on the terms and conditions – the fine print – in the policy. What is left over and billed to patients by the air transport companies is called the “Bill Balance.” This type of sticker shock, leaves the patient to pay tens of thousands in charges has been reported by a number Borregans, ostensibly because they were facing a life and death emergency, and flown to San Diego and Riverside hospitals. The words “out-of-pocket” used by both Mercy Air and REACH is a term in air evacuation insurance claims that is confusing to many that might be inclined to believe it covers the entire bill. It does not. It’s the amount an individual has agreed to pay out of their personal pocket as their contribution towards medical bills, per their insurance plan and costs left after third party payers have made their contribution. The patients share is controlled by the fine print called terms and conditions in insurance policies, and is occasionally open to negotiations with the insurance and air evacuation companies to reduce the patient’s “bill balance” owed to the air evacuation company. The other half of the cost equation is what the air emergency ambulance company charges. They are free to set their own rates, and aren’t regulated by either the federal or state governments. Although states like California have made some inroads into combating the financial pain called “Surprise Billing.”

Between the easily misunderstood advertisement that comes with REACH’s consumer membership programs, versus Mercy Air’s claim that membership programs are an illegal and unnecessary rip-off, it’s hard to separate the facts from the claims of company representatives and websites. Each claim to be the best when it comes to containing consumer costs. That’s because the biggest criticism of the industry are high costs, overcharging, unnecessary transports, or “surprise billing” that gets passed onto the patient.

Other issues of important comparisons range from the companies’ flight safety records, to differences of medical experience in medical staffing and pilot experience, helicopter models, onboard medical equipment, and “in” versus “out of network” costs. However, the big problem is the unwillingness to disclose costs before the helicopter leaves the pad, or the overhead, and fixed costs, which the air emergency company claims. And, the fact that costs, flight safety criteria, on board medical equipment and medical staffing for private air ambulances aren’t regulated by the federal government.

The bottom line, or the pertinent facts that apply generally to Borrego residents are: Anyone, who resides or visits Borrego Springs may one day need an emergency air evacuation. Due to its distance from hospitals that can handle critical illness or accidents, and where time is a factor in a patient’s prognosis, speedy air evacuation from Borrego to a hospital emergency room or trauma center is a medical necessity. Even though the odds of requiring air evacuation are small in the overall population, due to the older age of the population, emphasis on outdoor and sports recreation, and lack of critical emergency care in Borrego Springs, the odds increase.

Borrego Springs residents are fortunate to have Mercy Air medical evacuation helicopter based in the community. It reduces travel time to specialized medical care when it’s a matter of life or death. Before situating in Borrego, it took Mercy Air 25 minutes to fly from its base in El Cajon to retrieve a critically ill patient in Borrego Springs. That’s an extra 25 minutes before contact, and when minutes count, having air evacuation services located adjacent to the Borrego Springs clinic is definitely a medical advantage for the entire 92004 zip code.

The Borrego Valley Endowment Fund (BVEF) provides coverage of out of pocket costs including, deductibles, co-pays and cosponsors up to $700. However, this agreement is applicable to Mercy Air only, since BVEF cancelled their previous agreement with REACH. According to Bruce Kelley, who negotiated the Mercy deal, “attempts to reconcile costs with REACH for a similar agreement have not materialized.”

REACH membership may be purchased online, and costs $65 for individuals over 60 years of age, and $85 for family coverage. These benefits, which also include out of pocket expenses, are invalid if a patient is flown by Mercy Air. Reach coverage does not apply to the uninsured and is not an insurance plan.

“As part of the Community Partnership agreement between Mercy Air, and BVEF, Mercy Air agrees to accept as payment in full (for emergency air medical transportation on its helicopter) the combination of what it can collect from insurance plans, plus up to $700 from BVEF, which relieves Borrego Springs residents of all out-of-pocket expenses,” confirmed, William C. Hinton, RN, area manager, Air Methods – Pac West.

The agreement covers all residents of Borrego Springs, including anyone that resides here for at least one month, per year, whether they are insured or not. According to Hinton and Kelley, the BVEF/Mercy Air also covers Borrego residents in any geography where Mercy Air or its affiliates provide service.

For uninsured residents, Mercy will only collect up to $700 from BVEF. And claims it will accept that as payment in full. Hinton reiterated that, “After Mercy Air/Air Methods receives final payment (if any) from any third-party payer(s), the BVEF participates in the cost-sharing of any balances, up to $700 per transport. There is no further obligation from the patient, no balance bill.”

This bears repeating: Hinton and Kelley both claim, “For all our patients under the BVEF, our Patient Advocacy Team will work with them, and if it’s determined that the patient has no third party payers available, then that patient, regardless of financial situation, will not have any out pocket cost and the BVEF would cover the cost-sharing amount of $700.” Interpret this to mean, if an uninsured person has money, or is without money to cover the bill, Mercy Air will settle for the BVEF $700 contribution and not pursue any further payments.

Remember this quote if needing a medical necessity evacuation.

Also, understand, if the emergency fight is determined to be a non-medical necessity all bets are off.

Warning. It’s a buyer beware market. Despite the promises, affiliates of Air Method, are involved in class action lawsuits for overcharging, and harassing patients for payment. And the surprising, considerable bill balances after third party payments such as government funded, Medicare and Medicaid, employee and private health and travel insurance have contributed, continues to be the biggest consumer complaint of medical air evacuation or transport.

A local man received a flight bill of $60,000. The shocker was thousands in BSFPD ground ambulance fees. It’s important to note that an emergency patient generally has no choice of emergency air companies, unless that person is able to schedule their own flight company, which may happen in some medical emergencies, such as donor transports, or travel from one hospital to another in a county or to another state.

This is an important aspect of coverage, since Borrego’s seasonal residents, often live in other states. After the emergency transport to a San Diego or Riverside County trauma center or hospital, patients facing a long recovery usually want to transported to their local hospitals, and close to family. The cost of bedside to bedside transport may or may not be covered by the local providers or an individual’s insurance.

The process for assigning a company, according to Borrego Springs Fire District, is as follows. “Once the Fire Department paramedics arrive on the scene and have assessed the situation and patient (or patients) they call their assigned hospital to give a patient report and receive any medical orders beyond the standard medical protocols set forth by the County EMS medical director. Paramedics speak directly to a specialty nurse at the assigned “’base station’” hospital, who is known as a Mobile Intensive Care Nurse (MICN for short). In the case of the Borrego Springs Fire Protection District (BSFPD), they are assigned to Palomar Medical Center for medical coordination. The base station (Palomar Medical Center) facilitates all calls that the BSFPD is handling, regardless of the destination hospital. This does not imply all patients that the BSFPD encounters must be transported to Palomar Medical Center.

“The decision to transport a patient via an air medical helicopter is done through protocols issued by the County EMS agency. These protocols help ensure medical appropriateness of a requested transport by helicopter.

The fire department paramedics can make the determination to request treatment and transport by an air ambulance based on their assessment the patient while following these protocols. They may sometimes ask the base station hospital for some guidance on the appropriateness of using the helicopter. Once the decision is made to use the medical helicopter, County protocols guide the dispatch. In San Diego County, the dispatch protocol calls for the closest, most appropriate air ambulance to be dispatched – closest to the patient or incident.

“It is best to take a patient to the closest, most appropriate hospital that can best care for them and the patient destination (hospital) is often dictated by County policies. For example, trauma patients are to be taken to the closest County-designated trauma center, and patients experiencing a heart attack should be transported to hospitals that can immediately care for that patient upon arrival. Sometimes, the most appropriate hospital is where the patient’s primary physician is located and Mercy Air can usually accommodate a patient request.”

Insurance coverage and billing is often based on whether the patient is transported to an “in network” hospital. In other words, a hospital and medical staff with which an individual’s insurance company has a contract for discounted billing. “Out of network” billing or being under the care of providers with which the insurer has no financial agreements increases the cost to the consumer. “In” and “out of network” considerations are not top of mind when air transport is an emergency.

That’s a problem that can only be addressed by regulatory action at the federal and state government level. Both the perceived under payment of negotiated billings by the government insurance agencies, as well as the ability of emergency air flight companies to set their own prices are among the unaddressed regulatory issues that factor into the high costs.

The bottom line in anticipating costs for anyone, who might wisely, contemplate the possibly of needing an air evacuation for themselves, a spouse, or family members, are the terms and conditions of the individual’s health or travel insurance.

If the terms and conditions don’t answer questions or provide definitions of terms such as “medical necessity” versus non-emergency coverage, “in and out of network coverage,” bedside to bedside transfer, “bill balance” or client costs, adequately or in a way that is understandable, the individual should speak to an agent. And, get any and all confirmations of verbal coverage, signed and on paper.

This is true of Medicare and Medicaid, or Medi-Cal, since there are distinctions between A and B coverage and, where, and when, a Medi-Gap insurance can reduce direct client costs.

Some insurances have limits on costs, services, or definitions of what is as “medical necessity” and reimbursable, versus a “non-medical emergency.” For example, a man paid more for the transport of his lung for an organ transplant than he did for the entire medical procedures and rehabilitation costs. Other examples are: broken bones may not be a medical emergency, delivering a baby may not be a medical emergency, the list of disclaimers is what is left out, or not covered in an individual’s insurance policy, and, therefore, leaving the patient financially accountable for the bill balance.

There has been criticism that too many people, who are evacuated aren’t actually medical necessities. When in doubt, or out of concern for their own liability, most paramedics, and others involved in declaring a medical necessity will recommend transporting the patient just to be on the safe side.

Flanders, the spokesperson for Mercy Air said, “To keep a base costs $3 million a year.” Others in the industry have placed the cost at $6 million, and may not include the price of the helicopter, which vary according to models.

The overhead factored into a flight without any other variables appears to be the overhead, a highly guarded piece of the financial puzzle, since neither air carrier when interviewed would share, even a hypothetical example. The other variables the flight company incurs as costs include the price of fuel, insurance, the distance traveled, the medical needs of the patient, and whether they include bedside to bedside transfers to a hospital of choice, or home town hospital closer to family.

Word of advice: When facing a critical medical decision about the need for an air evacuation, it’s too late to worry about the costs. Because at that moment nothing else matters except a loved one in a life or death crises. However, the aftershock of significant billings from the flight companies, not covered by insurance, can be as life changing as the actual crisis.

The answer to buying supplemental air medical flight insurance or memberships, beyond what is available in Borrego Springs, is to research policies and what they cover, and buy real supplemental travel or additional air evacuation coverage. Just in case Mercy Air is not available, and REACH is the closest available transport, it might be wise to subscribe to REACH’s membership plan, for additional financial protection, even with the BVEF/Mercy agreement, which costs Borrego residents nothing.

Not discussed by either Mercy Air or REACH, is the case of a major disaster such as an earthquake, multiple vehicle accident or any situation where multiple individuals need emergency air lifts. The disclaimer is, if both REACH and Mercy Air are occupied, or not available, the individuals will not be able to plan for the costs, or the company that will dispatch them.

To those concerned about not having an emergency flight guarantee 24/7-365 days a year, or a supplement that provides domestic and international coverage, there are companies, like Medical Air Services Association (MASA), which don’t own, and aren’t affiliated with any air ambulance company, but contract with select companies and resources.

These are prepaid plans, which are more agent than equipment, orientated. They cover more services that are consequences of emergencies and disasters than simple air transport companies with limited availability, or services not covered by insurance. MASA claims to cover unlimited air emergency flight and ground ambulance, organ retrieval and organ recipient travel, recuperation or repatriation services, escort transport, visitor and companion transport, non-injury travel, minor child and grandchild return, vehicle return, mortal remains transport, worldwide coverage, and pet return for a core membership fee paid yearly, or monthly, for a total of $600. More expensive plans add attorney advisory services, translation and cash advance.

At one time, the Borrego Chamber of Commerce had a discounted deal with MASA and carried applications. As in all things insurance or advertised, read the small print, compare providers, interview agents, and reviews of their service.