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Highmark pilot program to pay ambulance companies when patients not taken to hospital

September 23, 2018

Highmark will reimburse ambulance companies for certain calls where patients aren’t taken to hospitals as part of a new “treat-and-release” program.

Highmark and Allegheny Health Network announced the pilot program Wednesday.

Currently, Highmark’s benefits and medical policy, similar to most insurers’ policies, only allows payment for emergency ambulance services when the patient is taken to an emergency room.

“We want to ensure that ambulance services are paid appropriately and members receive appropriate care,” said Robert Wanovich, vice president of ancillary provider strategy and management for Highmark.

Sixteen ambulance services across 12 counties are participating, according to spokeswoman Stephanie Waite. They include Butler Ambulance, Cranberry Township EMS, Kittanning EMS, Medical Rescue Team South, Mon Valley EMS, Pittsburgh EMS, Plum EMS, Ross West View EMS, Rostraver EMS and Valley Ambulance.

Waite said Highmark is not disclosing how much it will pay ambulance companies per call under the program.

Under the pilot program, Highmark will contract with and reimburse participating emergency medical services for treating patients age 18 and older who have low blood sugar, asthma attacks and seizure disorders, without the requirement of being taken to an emergency department.

“The goal of the pilot is to reduce unnecessary emergency department visits and improve the overall patient experience, decrease health care costs and ensure that ambulance services are paid fairly and members receive appropriate care,” a Highmark news release said.

Patients will be treated and assessed on-scene based on standard state-approved protocols and under the oversight of an emergency medicine physician. Allegheny Health Network staff will follow up by phone within 48 hours to check the patient’s condition.

“As a hospital system, patient care is our highest priority,” said Robert McCaughan, vice president of pre-hospital care services for Allegheny Health Network. “If patients who call for an ambulance in non-emergent situations can be assessed and treated on-site, that helps free up our emergency department and emergency department staff - as well as the ambulance service - for true emergencies and more efficient patient care.”

Brian Maloney, director of operations for Plum EMS, called the program a good one.

“Insurance doesn’t cover anything unless we transport to the hospital,” he said. “A lot of times we show up, we treat and many times because it’s a recurrent issue for them they don’t go to the hospital. What we provide them prevents them from going to the emergency department.”

Treat-and-release “can prevent a lot of money from being spent where it doesn’t have to,” he said. “It’s a step in the right direction. It’s a significant step as well.”

What Maloney said he likes the most about it is the follow-up call.

“I really like the approach that’s being taken here,” he said.

Wanovich said that patient participation in the pilot program is voluntary.

“If a patient wants to be transported to a hospital, they will be,” he said.

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