Following an air ambulance ride from Colorado to North Carolina, a cancer patient received a nearly $500,000 bill, Julie Appleby writes for Kaiser Health News—something that may have been avoided under the No Surprises Act.

Infographic: The patient financial journey

A sudden cancer diagnosis

In 2020, Sean Deines and his wife Rebekah were visiting his grandfather in Wyoming when Deines began feeling severely ill. At his wife's urging, Deines went to an urgent care center.

"Your white blood count is through the roof," Deines recalled a staffer at the urgent care center telling him. "You need to get an [ED] right now."

The couple then drove to a hospital in Casper, Wyoming, but were soon airlifted to the University of Colorado Hospital where Deines was admitted on Nov. 28, 2020. At the hospital, specialists diagnosed Deines with acute lymphoblastic leukemia, a fast-growing blood cancer.

"Literally within 12 hours, I needed to figure out what to do with the next step of my life," Deines said.

Deines was quickly started on intravenous treatments, including antibiotics and steroids. After he stabilized, Deines and his wife decided they would continue his treatment at Duke University Medical Center in North Carolina where they were originally from.

To get to North Carolina, Deines and his wife employed the services Angel MedFlight, a medical transport company that is part of Aviation West Charters. According to Appleby, the company told Deines' wife it would accept whatever the couple's insurer would pay and that they would not be responsible for the remaining balance.

Deines was flown to North Carolina on Dec. 1, 2020, before a ground ambulance took him to Duke Medical Center, which was in-network, and where he stayed as an inpatient for 28 days.

How a medical transport ended up costing nearly $500k

After Deines was discharged from the hospital, he received a $489,000 bill for his medical transport. Most of the bill was for the flight from Colorado to North Carolina, but around $70,000 was for the ground ambulance service Deines had taken to and from airports in both states.

Although Angel MedFlight sought prior authorization from Deines' insurer, Blue Cross Blue Shield of North Carolina, the company went ahead with the flight before it was approved. On Dec. 3, 2020, the insurer denied coverage for the air ambulance services, saying that "medical records did not support that it was an emergency and Deines was already in an appropriate medical facility," Appleby writes.

At the end of December 2020, Angel MedFlight appealed the insurer's decision to deny coverage on behalf of Deines. Then, in March 2021, Deines' insurer sent him a check for $72,000 to cover part of his $489,000 bill—but three months later, Deines was asked to pay back the money.

Angel MedFlight continued to appeal the insurer's determination that Deines' flight was not medically necessary, moving their efforts to an independent third-party evaluator through the state of North Carolina in June 2021.

Ultimately, the evaluator ruled in favor of the insurer. Although the review noted that Deines was "medically unfit to travel via commercial airflight," it concluded that the travel was unnecessary since Deines could have been treated at his original Colorado hospital.

In the end, Deines' exorbitant bill was resolved after a Kaiser Health News reporter contacted communications representatives for both the insurer and Angel MedFlight. Both companies said that Deines would no longer be held responsible for any of his medical transport charges.

Could the No Surprises Act have changed this outcome?

The No Surprises Act, which took effect Jan. 1, is aimed at protecting insured patients from surprise medical bills, including "balance bills" in emergency situations and non-emergency treatment from an out-of-network provider at an in-network facility.

In addition, the law also requires providers to provide a "good faith estimate" of the costs of their services. Under this provision, medical providers, including air ambulances, must give patients upfront cost estimates in nonemergency situations.

According to Appleby, if the No Surprises Act had been in effect when Deines' flight occurred, he probably would have received more price information and learned that the transport could be billed at $489,000. However, the law likely would not have impacted the main point of contention in Deines' case—whether his flight was considered a "medical necessity." Currently, insurers have leeway to define medical necessity and deny coverage for procedures that don't fit their criteria.

For his part, Deines said that, despite the shocking bill that came later, he was glad he took the flight to be closer to his home and family.

"I would not change it, because it provided support for myself and my wife, who needed to take care of me; she was keeping my sanity," he said. (Appleby, Kaiser Health News, 3/25)