DENVER — When two parents were billed tens of thousands of dollars after their son had a medical emergency, their insurance company initially said it wouldn't pay.
During the RSV outbreak in December of 2022, Kelly and Chris Calero didn’t hesitate when their son Ethan began having trouble breathing. They took him right to Children’s Hospital South in Highlands Ranch.
As his condition worsened overnight, doctors told the family he needed to be transported 24 miles away to Children’s Hospital’s main campus in Aurora.
“When you see all the medical people around, you start to get really concerned,” Kelly said. “That's when you as a parent are like, 'Whoa, this could go south really fast.' And it's really scary.”
The Caleros said that doctors told them it would take six hours for the right ground ambulance to get to the hospital. So, the doctors chose to send Ethan to Aurora aboard a helicopter air ambulance. They said there really wasn’t a choice.
They flew him to Aurora and Ethan recovered.
Nearly a year and a half after that ordeal, the Caleros were still fighting with their insurance company to cover the nearly $60,000 bill from the ambulance provider, Reach Air, until Steve On Your Side got involved.
“We got the bill and I thought, okay, stay calm,” Kelly said. “We're gonna go through all through this process.”
She assumed insurance would cover the bill. Her husband, Chris, said he called their insurance company, Anthem Blue Cross Blue Shield, after the claim was initially denied in February 2023. A representative told him the ride should be covered and she would initiate an appeal.
In November, they got notice that their appeal was denied.
“[The insurance company said] that it wasn't too dangerous for him to be to wait for ground transportation,” Chris said, remembering what he read in their denial letter.
He said medical records clearly show Ethan was in serious distress and needed the transport. The family said they contacted Children’s Hospital and got a letter of medical necessity to submit with a second appeal.
That second appeal was denied earlier this year.
“It just put our entire life on hold,” Kelly said. “Like right now we're renting, and we'd like to buy a house. But we have to wait to find out what our financial situation is going to be.”
Their denial echoes stories of other air ambulance bill denials.
Last month, Steve On Your Side profiled a Castle Pines family whose daughter needed the same air transport as Ethan Calero. Their insurer, also Anthem Blue Cross Blue Shield, denied the $60,000 bill until Steve On Your Side asked about it.
In California, a family was denied a $97,000 air ambulance claim for a 3-month-old with RSV who needed to be transported to another hospital 100 ground miles away after the insurance claimed a ground ambulance could have handled the transport, KFF Health News reported. The child’s doctor ordered the helicopter.
KFF Health News reporter Molly Castle Work pointed to a February letter from the head of the National Association of EMS Physicians (NAEMSP) to several Cabinet secretaries including Health and Human Services Secretary Xavier Becerra.
In the letter, the trade group said it has noticed a wave of insurance providers denying air ambulance bills since the 2022 No Surprises Act became law. That law prevents health care providers from billing out-of-network patients a balance bill after an insurance carrier pays a claim.
But Castle Work said that, under the law, an insurer can deny a claim if they deem the service not medically necessary.
“Our understanding is that when plans deny a claim due to being medically unnecessary, they're basically able to sidestep the law,” Castle Work said of her reporting on the California bill.
Insurers, including Anthem, have pushed back on the costs of these flights in the first place. Castle Work said rising prices have to do with private equity gobbling up air ambulance companies. She also said the No Surprises Act has created a climate for increasing prices.
“There's a requirement if an insurance company and an ambulance or disagree on how much it should be covered, they basically have a chance to duke it out — and then that can go to a federal appeal process,” Castle Work said. “What we've been told is that ambulances are winning most of the time in the federal appeal process. So they basically are feeling more license to keep raising those prices.”
The NAEMSP is petitioning the federal government to change the definitions of medical necessity, essentially requiring an insurance company to cover a claim if a licensed doctor at a hospital deems a transport as medically necessary.
When Steve On Your Side asked Anthem about Ethan Calero’s claim, the insurance provider said the air ambulance company didn’t provide Anthem all the necessary medical information.
“After receiving more information about this member’s medical condition from Children’s Hospital Colorado, the claim was approved,” the statement from Anthem said.
Days after Steve On Your Side contacted Anthem, the company called Chris Calero to tell him the claim would be processed. A fight that lasted nearly a year and a half was over.
“It feels like we can have some peace,” Kelly Calero said. “Our kids are going to be healthy. And we're going to just move on.”
Have a tip for Steve On Your Side? Contact 9NEWS Consumer Investigator Steve Staeger.
More reporting by Steve Staeger:
SUGGESTED VIDEOS: Full Episodes of Next with Kyle Clark