By Bill Toland
Pittsburgh Post-Gazette
SHALER, Pa. — On an emergency call last weekend, Shaler Area EMS employees encountered a patient who was reluctant to board the ambulance.
“I can’t go with you,” the patient said, according to a retelling from Joe Johnson, manager of Shaler Area EMS. “I have UPMC Health Plan.”
Problem is, that’s not true, Mr. Johnson said.
The confusion stems from a letter that UPMC Health Plan sent to hundreds of Shaler area residents this month, saying that Shaler’s primary ambulance service is “no longer [a] participating provider,” and implying that patients would have to “transition” to a new EMS company.
“The letter itself is very misleading,” Mr. Johnson said. That’s because, regardless of an ambulance company’s network affiliation, an insurance company is obliged by state law to pay for medically necessary emergency transport services.
In other words, in an emergency, Shaler residents should still call 911 and their trip in the ambulance will still be covered by UPMC Health Plan, even if the transporting ambulance company is Shaler Area EMS.
On Wednesday, UPMC confirmed that.
“Shaler EMS remains available to all of our members for their emergency transport needs, including all 911 transports,” health plan spokesman William Modoono said.
“We do understand that a letter we sent to the 206 members who had used Shaler EMS for transportation in the past year may not have been clear enough in this regard. We have since reached out to each of these members to make certain they understand that Shaler EMS is available to them” for all emergencies.
The letter was born of Shaler EMS’s decision to exit the UPMC Health Plan, Mr. Johnson said. For years, the ambulance company had been an in-network provider with the plan. As part of the network, Shaler EMS agreed to a contract that paid it a set rate for emergency transports and for nonemergency trips, such as those to a nursing home.
By leaving the UPMC Health Plan network, Shaler EMS is no longer a preferred carrier for nonemergency trips. But it won’t miss those trips very much: Of the 251 UPMC Health Plan transports that it made last year, only 16 were nonemergencies.
The absence of the nonemergency revenue will be more than absorbed by an increase in emergency trip revenue, Mr. Johnson said. Instead of being bound by its $374 contractual reimbursement from UPMC Health Plan, Shaler is now free to charge UPMC its own rate: $945 per emergency trip.
This spring, Shaler EMS notified UPMC Health Plan that the ambulance company was pulling out of the contract. The “out-of-network” designation quietly went into effect in July.
But over the last few weeks, UPMC Health Plan has been sending out letters that confused, rather that clarified, the situation.
Mr. Johnson says he believes UPMC Health Plan made an honest mistake.
The letter that residents received, he said, is the same type of letter that the insurer sends to affected patients when a physician or practice leaves the UPMC provider network.
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©2014 the Pittsburgh Post-Gazette