Flo Nibbling, 76, a Medicare recipient, for years never paid a cent for medical emergency treatment in her home or ambulance transport to the hospital. Then, in July, she fainted. It was the beginning of a stroke. A bill for $444.35 from the company that treated her arrived soon after. The bill noted that Medicare had denied the claim. Formerly, Medicare had paid 80 percent of the bill and her secondary insurance would have picked up the rest.

Nibbling says she hasn't paid the bill because she doesn't have the money. 
"I'd rather die in my living room," Nibbling said, "than pay bills such as this."
Nibbling's experience is the result of recent changes to Medicare's billing system, that has municipalities fighting with hospitals over emergency medical care bills. State officials say Medicare billing, along with a decline in the number of ambulance corps volunteers, are resulting in a near-crisis for the state's emergency medical services, or EMS, system.

"To prevent a crash of the system, we have to conduct preventative measures," said David Gruber, assistant commissioner for the state Department of Health and Senior Services, by telephone last week. 

Medicare at one time accepted bills from multiple emergency service providers who responded to a single 911 call. Then it announced it would accept only one bill, even if two providers were involved. Finally, last year, Medicare phased in new payment rates for EMS providers that drastically realigned who would get how much. As a result, patients are getting bills for what Medicare won't pay. 

Meanwhile, hospitals are making slimmer profits on the highly skilled technicians they send out, while ambulances dispatched by municipalities are pocketing money hospitals used to get.

Gruber plans to announce proposals to the EMS system, including Medicare billing and other aspects, when he attends the New Jersey Statewide Conference on EMS, to be held Wednesday through Friday at the Atlantic City Sheraton. The statewide EMS system is run by 25,000 volunteer and paid personnel. 

New Jersey's EMS structure is different from those of most states. Typically, when a person is in a life-threatening emergency, two squads arrive: one to administer emergency medical treatment and another to transport the patient to the hospital. 

In many states, just one ambulance arrives. In New Jersey, state law bans the skilled treatment provider from transporting a patient to the hospital, the rationale being to free up the highly qualified emergency personnel to take other calls.

The two-tiered system is lauded by some -- New Jersey is one of the few states that attempts to guarantee 100 percent coverage of the state with highly qualified medical technicians at all times.

But it's created a billing nightmare that's affecting people like Flo Nibbling. Last year, Medicare, an arm of the federal government that helps pay medical costs for the elderly, phased in new rates for emergency medical care.

Maximum rates are now higher than before for the transport company, and lower for the treatment provider. Medicare's rate in North Jersey is $431.85 for treatment -- called "advanced life support," or ALS -- and $363.66 for transport, or what it calls "basic life support," or BLS.

The change in Medicare reimbursement rates has become problematic because Medicare has a policy of accepting only one bill for a single emergency call. It will pay either the transporter or the treatment provider, but never both.
This means that in municipalities with paid ambulance squads, hospitals sometimes fight with municipal officials over Medicare reimbursement for a single 911 call.

In Clifton, officials have been involved in a dispute with Monmouth Ocean Hospital Service Corp., or Monoc, a nonprofit consortium of New Jersey hospitals that provides emergency paramedic treatment out of various hospitals. It is the state-designated treatment provider for 25 percent of the state, including Clifton, Passaic, North Arlington and Lyndhurst.

The Clifton dispute arose because Monoc wants 100 percent of Medicare reimbursement for both services, while Clifton wants its share. To date, Clifton has been getting the reimbursement since Medicare prefers that transport providers submit bills. As a result, Monoc has started to bill patients.

Clifton City Manager Al Greco said the city wouldn't mind if Monoc billed Medicare for both services as long as it gives Clifton some of the revenue. 
But Monoc says that if it gave Clifton the city's share of Medicare reimbursement, the service would be left with only about $60 for one call. That simply isn't profitable for Monoc, said Jeff Behm, operations director for the Neptune-based consortium.

"There is nothing that says the (transport provider) can or cannot rake me over the coals," Behm said. 

Greco meanwhile believes that Monoc's insistence on keeping 100 percent of the revenue is unacceptable. 

"They were trying to be cute," he said.

Because neither party will budge, Clifton has been billing Medicare -- and getting its portion of the reimbursement. Monoc, unable to collect, has been billing Clifton patients.

The same scenario is being played out in Passaic. City spokesman Keith Furlong said the city hasn't been able to negotiate what it considers a fair Medicare billing agreement and Monoc has been billing Passaic Medicare patients.

Another problem facing the state's EMS system is a decline in the number of volunteers to work on ambulance squads.

Harold Cohen, a Virginia-based consultant the state hired to report on its EMS system, said the dwindling number of ambulance corps volunteers is a problem nationwide as more people hold jobs and work longer hours. Five years ago, volunteers in New Jersey staffed 70 percent of ambulance squads, compared with slightly more than 40 percent today, Gruber said. 

"When you start losing the people," he said, "you start losing the ability to respond."

Mark Veenema, director for St. Joseph's Regional Medical Center's paramedic service, said the ambulance squad volunteer shortage is so acute that his crews often arrive before the volunteers. The problem has meant delays in getting patients to the hospital, he said, because of the state's law that the treatment provider in life-threatening emergencies cannot transport patients. 

"Today you call 911 and paramedics arrive," Veenema said, "but there's no transportation." The longest St. Joseph paramedics have waited for a transport ambulance to arrive is one hour and 56 minutes, he said. 

Short on volunteers, some municipalities are turning to private companies for daytime ambulance coverage.

"There's a trend toward paid in the daytime," said Howard Meyer, legislative director for the New Jersey State First Aid Council, an association for the state's volunteer ambulance corps. 

But he disagrees with state officials that the EMS system is in crisis. The best help the state can give is to help establish new ways of training volunteers, he said. He suggested training people online. The 120-hour training most volunteer corps demand is only offered in classrooms, he said. An online course for emergency medical technicians is overdue, he contends. 

Online courses exist for even improbable pursuits, he said.

"They're teaching people online how to become ski instructors in Florida," Meyer said.