NASHVILLE, Tenn. (WTVF) — If you've got a full-time job, you probably have health insurance and part of your paycheck may even go to help pay the premiums. Having that coverage is important because it helps pay your medical bills, especially when you have a medical emergency. Or at least that's what it's supposed to do.
But customers of BlueCross BlueShield of Tennessee said the company is refusing to cover an important medical service and that's leaving them with bills they have no way to pay.
When there's a medical emergency, minutes can mean the difference between life and death.
Rob Shelton recalled his own medical emergency.
"I felt like something was wrong. I felt like I was gonna have to call 911," he told NewsChannel 5 Investigates, adding. "I made it about halfway down the stairs and that’s when I blacked out."
After Shelton had a stroke at his home in Nolensville, paramedics raced him to the nearest hospital, StoneCrest in Smyrna, where doctors quickly determined he needed the kind of care they couldn't provide.
They wanted to move him to Skyline Medical Center some 25 miles away, which can take more than half an hour under the best conditions.
So doctors called Air Evac, a medical air transport company with helicopters staffed and equipped like an ICU.
"There really wasn’t a choice as far as the flight. It wasn’t, 'Hey, you can have a flight or an ambulance or you can drive yourself.' It was 'He could die. We are taking him,'" Shelton said.
While Air Evac is an in-network provider and the trip should have been covered under Shelton's policy with BlueCross BlueShield of Tennessee, he was billed for the entire amount.
"It was $51,000. I thought, 'How am I going to pay this?'" Shelton said.
For Steve Hedges who was in Camden at the time of his medical emergency, it was all of the symptoms of a heart attack.
The closest hospital was just a mile away in Benton County. But the paramedic who evaluated Hedges thought it would be better to fly him directly by Air Evac to St. Thomas West in Nashville.
"This was not your decision?" NewsChannel 5 Investigates asked Hedges.
"No, this was the EMT saying, 'You’ve got to do this.' You know I’m not a medical professional, but he was and I’m going to listen to him," Hedges said.
BlueCross BlueShield of Tennessee denied both Steve Hedges' claim and Rob Shelton's because the insurance company said the flights were "medically unnecessary."
Hedges was stuck with a bill for $65,000.
His reaction when he opened the bill?
"I’m like, 'Oh my God,'" Hedges remembered.
We asked Dr. Melissa Costello, an emergency room physician and national medical director for Global Medical Response, the parent company of Air Evac: "Shouldn’t Blue Cross Blue Shield be paying for this kind of service?"
Her response?
"Yes! It is part of the system of emergency care."
"Are they (BCBSTN) turning down (denying to pay for) trips that are actually medically necessary?" we asked.
"Yes, yes, yes. And they are turning down trips that a year or two years ago they paid," Costello said.
So why the change? Early last year, the No Surprises Act took effect, designed to protect patients from being charged extra for going out of network. But under the law, insurance companies can refuse to pay for in-network services they deem "medically unnecessary."
And according to Air Evac, no one is using the medical necessity clause to deny claims more than BlueCross BlueShield of Tennessee.
That's leaving patients like Rob Shelton stuck with huge bills they never thought they'd have to pay themselves.
"It’s a real kick in the teeth. There’s no doubt about that. You have insurance, and you pay for your insurance to make sure you’re covered by these things. And you expect your insurance company will cover it," Shelton explained.
BlueCross BlueShield declined our request for an interview, but forwarded an article the company had recently sent to members explaining that it is trying to "lower members' costs" and that it's "process for covering air ambulance services is similar to other insurers."
But, that's not true, according to Air Evac's parent company whose data shows BlueCross BlueShield of Tennessee last year denied substantially more claims than a long list of insurers across the country. In fact, BCBSTN denied more claims than the next three highest combined, including United Health Care, Blue Cross of Oklahoma and Blue Cross of California.
Dr. Costello believes the insurance company is discriminating against people who live in rural Tennessee where more and more rural hospitals are either closing or eliminating services.
"Blue Cross Blue Shield is creating a situation where they are comfortable saying that if you live in rural Tennessee, you should have a different standard of care. You’re not entitled to the care that we give in Nashville and Chattanooga and Knoxville because you live far away," Costello said.
Rob Shelton meanwhile feels he wouldn't be alive today if he hadn't been flown and gotten the care at Skyline that he needed. And he can't believe BlueCross BlueShield doesn't agree.
"So what do you think they’re making their decision based on?" we asked.
"Money, plain and simple," he replied.
Since we interviewed Shelton and reached out to BlueCross BlueShield, the company reversed course and agreed to cover Shelton's bill.
BCBSTN recently also agreed to pay Steve Hedges' AirEvac bill after a Grievance Committee determined that his flight had in fact been "appropriate due to the circumstances." That ruling came nearly 19 months after Hedges' heart scare.
Both men waited at least 15 months to finally have BCBSTN agree to pay for their flights. Both suffered their medical emergencies last year, Shelton in May of 2022 and Hedges in January of 2022. We're told that's pretty standard for the appeals process to take that long, though it's stressful as you might imagine for the patient who's got a huge bill out there with his or her name on it.
