Calling an ambulance in Manatee County can cost you $600. Or more.

If you call an ambulance in Manatee County for a medical emergency, you or your insurance company will get a bill, posssibly for as much as $600 or $700. You are responsible for this bill, just as you are responsible for your water and sewer bills. And the county puts considerable effort into collecting for Emergency Medical Services (EMS), so don't think an ambulance transportation bill from them will go away if you ignore it long enough, because it won't.

In fiscal 2009 Manatee County billed a total of $10,335,667 for EMS services, and collected $7,514,999, or about 75% of the amount due. Utilities Business Operations Customer Service Support Manager Barbara Redmond, who supplied these figures, says this is about $1 million better than the county did in fiscal 2008, not because people had more money in 2009, but because the county had forged a more efficient working relationship with Per-Se, the outside billing service they use.

Per-Se, so you know, is not a local entrepreneurial operation. Since 2007 it has been part of McKesson Corporation, the world's largest health care company.

Also note that, while EMS is part of the Department of Public Safety, it is the county's Utilities operation -- the people who send out county water bills -- that is responsible for collecting fees for EMS services. The service and the act of collecting for it are entirely separate, which is probably a good idea. I say this as someone whose life was very literally saved by Manatee County EMS, and I'm glad they were concentrating on getting my heart going instead of calculating a bill.

Most people never see EMS bills

Redmond says the majority of EMS bills are paid by Blue Cross or other private health insurance companies, Medicare, Medicaid, the V.A., auto accident insurance companies or workers comp carriers. And a major complexity users may never see in the billing process is that multiple insurers may each be liable for a portion of a bill. Add that factor to insurance companies' general propensity to hold onto a buck as long as they can, and, Redmond says, "it often takes six to eight months to collect" from insurance companies.

Here's another fun EMS billing fact for you: there's a list price for the service, and there's the amount a given insurance company or government agency such as Medicare or the VA will allow for EMS service. The insurance company or government price is always lower than full EMS "retail."

Now guess who pays full price. If you said, "People who have no health insurance and are paying out of pocket," you would be correct. Same as with most doctor and hospital bills, the very people in our society who can least afford to pay typically get socked the hardest.

Some EMS bills will never be collected

In December, 2009, Redmond says Manatee County wrote off 111 EMS accounts, a total of $45,364.03, because they were being billed to deceased individuals who left no assets behind.

Also in December, 2009 (the most recent month for which full figures are available), 12 EMS bills were written off because the parties being billed declared bankruptcy.

And some people who get billed are never found. First the billing company sends a bill. If it comes back, that bill soon moves to the collection agency, which goes to great lengths to find people who owe money to Manatee County, up to and including skiptracing. We don't currently have statistics on how many of these people there are, a statistic Redmond says she'll be asking the collection agency (MAF Collection Services, based in Tampa) to provide in the future. 

Writeoffs and payment plans

Those who love to pore through minutes of County Commission meetings will spot a bunch of little one-line or two-line "consent agenda" items near the bottom of each meeting's agenda on which Commissioners typically vote yea or nay without much debate, if any. Among these consent agenda items you'll often see amounts being written off as uncollectable EMS debts. This doesn't mean those payments will never be collected, just that they've been sent to the collection agency, where it seems like only 4.4% of them are being collected -- an amount Redmond assures us is actually toward the top end of the typical collection rate for EMS debt, which generally ranges from 2% to 5%.

These writeoff amounts can vary. I've seen amounts ranging from around $180,000 to over $300,000 at a time, and they don't seem to come with any standard frequency. But they are ongoing, and obviously add up to a considerable sum at the end of the year, even though Redmond points out that the main reason EMS billed more than $10 million in 2009 and only collected about $7.5 million was less-than-full-price payments from insurance companies and government age1ncies.

Now we move into a moral grey area: How hard do we want to pursue collections efforts against people who may be unemployed, broke, possibly even homeless?

Redmond says the county works hard to accomodate people who don't have cash to pay, arranging payment programs that require as little as $10 per month to keep the collection agency at bay. And even after an account has been sent to the collection agency, if either the county or the billing company learn of any way to charge that bill to an insurance company or government agency -- basically, to anyone other than a beleagured patient -- they will stop collection attempts and redirect that bill to the appropriate party.

And there's the fact that individuals, usually the people who have the most trouble paying, are expected to pay more than insurance companies or government agencies for the same medical services, including EMS. Is this fair? Hardly anyone I've talked to while working on this story thinks so.

Even Barbara Redmond, the person we Manatee Countians hold responsible for collecting EMS debts for us, has doubts about this system. She's a dedicated publc servant who does her best to do right by Manatee County taxpayers, which means she tries to collect as many EMS bills as she can.

But despite this responsibility, when Redmond talks about how the county's EMS collection efforts affect patients and their families, she says, "Sometimes, it breaks your heart."