It was the first — and only — time Dr. Naveed Khan, a 35-year-old radiologist, ever rode in an all-terrain vehicle.
Khan took the wheel from his friend and drove circles in the sand, on a trail along the Red River in Texas.
"As soon as I turned to the side where my body weight was, this two-seater vehicle ... just tilted toward the side and toppled," Khan recalled. It landed on his left arm.
"I had about a 6-inch-wide exposed flesh gap that I could see below, on my forearm," he said. "And I could see muscle. I could see the fat. I could see the skin. The blood was pooling around it."
Khan, feeling lightheaded, tied his jacket around his arm like a tourniquet. He and his friend managed to right the ATV, drive back toward the street and call 911.
When an ambulance delivered him to the emergency room at United Regional Health Care System in Wichita Falls, Khan was surprised to hear a doctor murmur that it was the worst arm injury he'd ever seen.
Khan needed immediate helicopter transport to a trauma center for surgery in Fort Worth, if there was any hope of saving the arm.
Groggy from painkillers, Khan managed to ask the doctors how much the flight would cost and whether it would be covered by his insurer. "I think they told my friend, 'He needs to stop asking questions. He needs to get on that helicopter. He doesn't realize how serious this injury is,' " Khan recalled.
Flown 108 miles to John Peter Smith Hospital in Fort Worth, the closest Level I trauma center, Khan was whisked into surgery to clean out the wound, repair his shattered bones and get blood flowing to the tissue.
He had a total of eight operations to try to save his left forearm before he finally gave up. After weeks in the hospital, he asked the doctors to amputate, so he could get on with his life.
And then the bill came.
Patient: Naveed Khan, 35, a radiologist and married father of three young children in Southlake, Texas.
Total bill: $56,603 for an air ambulance flight. Blue Cross Blue Shield of Texas, Khan's insurer, paid $11,972, after initially refusing altogether; the medevac company billed Khan for the remaining $44,631.
Service provider: Air Evac Lifeteam, an air ambulance company that operates 130 bases in 15 states. It's owned by Air Medical Group Holdings, a holding company that owns four other air ambulance companies and one ground ambulance company. Air Medical, in turn, is owned by the giant private equity firm Kohlberg Kravis Roberts.
Medical service: Khan was flown from the United Regional Health Care System in Wichita Falls, Texas, to the John Peter Smith Hospital in Fort Worth.
What gives: Khan got his first call from Air Evac Lifeteam just three days after the accident, while he was still lying in the hospital. A company representative told him the helicopter ride would most likely cost more than $50,000 and asked him how he planned to pay.
For Khan, rapid transportation to the trauma center was essential since the blood supply to his arm had been cut off, said Dr. Rajesh Gandhi, the medical director for trauma services at JPS Hospital.
"If there's no blood going that means there's no oxygen," he said. "It there's no oxygen, that means those cells are going to die." Minutes are precious and the helicopter can get from Wichita Falls to Fort Worth in an hour or less, half the time it takes by ground ambulance, he said.
But complaints about sky-high bills to patients for air ambulance services are common. Since launching the "Bill of the Month" series in February, NPR and Kaiser Health News have received more than a dozen bills from patients like Khan who were charged tens of thousands of dollars for an air ambulance ride even after insurers' payments.
Air ambulance companies defend their charges.
Rick Sherlock, president of the Association of Air Medical Services, a trade group, said air ambulances require a more highly trained crew than a ground ambulance, because only the sickest or most seriously injured patients need air transport.
AAMS commissioned a study to determine the actual cost of a medevac ride. The report found it takes about $2.9 million a year to run a single helicopter base. Each base handles about 300 transports a year, and the rides cost about $11,000 each, according to the report.
A spokeswoman for Air Evac Lifeteam said the company bills people so much because it is trying to make up for what she said are meager payments from Medicare and Medicaid.
"Our real cost per flight is the $10,200 plus the unreimbursed cost on each flight for Medicare, Medicaid and patients without any coverage," wrote Shelly Schneider, the company spokeswoman.
The Centers for Medicare & Medicaid Services said it pays an average of $4,624 per ride, plus $31.67 a mile, which works out to an average Medicare reimbursement of $6,556 for helicopter ambulance rides for seniors. Medicaid in most states pays less.
The industry has been advocating hard to get Medicare to boost its reimbursements, Sherlock said. There are bills pending in both the House and Senate that would do so, but there hasn't been much movement on them.
But others say the industry's cost estimates are inflated by profit-driven expansion of a lucrative industry. Ground ambulances often carry critically ill patients, too.
Too many air ambulances sit idle much of the time, said Dr. Ira Blumen, a professor of emergency medicine at the University of Chicago and medical director of the university's Aeromedical Network.
Blumen said the industry — which is dominated by a few companies owned by private equity firms — expanded dramatically in 2002, the last time Medicare boosted its payments. And now there are too many helicopters — 908 as of last year — fighting for patients and profits at the same time.
"The number of helicopters is outrageous for the continental United States," he said. In the 1990s, most helicopters ran more than 500 flights per year on average. At that rate, the cost per flight today would be less than $6,000.
A BCBS of Texas spokesman said the insurer does have a contracted rate with an in-network air ambulance company, but it is not Air Evac Lifeteam. After initially refusing to pay anything for an out-of-network claim, it agreed to the $11,972 payment.
But in some sense, the reason ambulance companies charge so much is simply that they can: Air ambulances are largely regulated not as health care but as part of the aviation industry. Federal laws prevent states from limiting aviation rates, routes and services.
So many people have been hit with shockingly high air ambulance bills that members of Congress on both sides of the aisle are trying to do something about it. Legislation to reauthorize funding for the Federal Aviation Administration that is moving through Congress now would create a council of industry experts to address balance billing and other issues and set up a complaint line for consumers.
Resolution: Khan has allowed Air Evac Lifeteam to negotiate with BCBS of Texas over the remaining $44,000-plus air ambulance bill. The company has asked him to appeal to the state's Department of Insurance, and though he first balked at the suggestion, he is now considering doing so. Khan said he doesn't understand why the helicopter flight, which was an integral part of the emergency medical care he received, is treated differently from his surgeries, nursing care and physical therapy.
"I thought that this was another piece of that puzzle," he said. "It turns out that this was glaringly different."
He is waiting for resolution as he gets accustomed to life with his disability. Holding his baby son, he asked in frustration: "How do I hold him while he's crying and at the same time heat up his bottle?"
Khan, who has had to fight with his insurance company to get coverage for a prosthetic arm, was frustrated when he learns that the air ambulance company expects him to pay far more than the actual cost of his flight.
"It's unfair," he said. "It's random; it's arbitrary. It's whatever price they want to set. And to put that onto a person who's already been through what I've been through, I hate to say it, but it's cruel."
The takeaway: Most people with health problems serious enough to require a helicopter flight are in no position to ask whether the medevac company is in-network or there's a choice. But if you or a family member has time to ask, it could pay off.
If you're faced with a huge bill for a medevac ride, there are a few steps you should take.
First, let your insurer's process play out. BCBS of Texas first denied Khan's claim altogether. But he looked closely at his policy and saw that the threat of loss of limb was explicitly covered. He appealed, and that's when the insurer paid $11,972.
Second, negotiate! The air ambulance company might be willing to negotiate a settlement for a fraction of the bill to avoid turning to debt collectors, who would pay them pennies on the dollar.
Both Sherlock of the Association of Air Medical Services and Schneider of Air Evac Lifeteam said companies will try to determine what a patient can afford. So people with high incomes may find it hard to obtain a substantial reduction for their bill. Still, if patients know the true cost of the service they received, they may be better equipped to negotiate a discount.
Many air ambulance companies offer membership plans that can cost less than $100 a year and guarantee that the company will accept whatever payment an insurance company makes without billing the patient for the rest. But buyer, beware: When people need an air ambulance, they are often not in a position to choose which company will respond to the call.
Bill of the Month is a crowdsourced investigation by Kaiser Health News and NPR that dissects and explains medical bills. Do you have an interesting medical bill you want to share with us? Tell us about it!
AUDIE CORNISH, HOST:
I'm Audie Cornish.
MARY LOUISE KELLY, HOST:
And I'm Mary Louise Kelly with the latest installment in our Medical Bill of the Month series. NPR, along with Kaiser Health News, has received nearly a thousand of your bills. They're often complicated. They are often expensive. A dozen listeners sent in bills for their air ambulance rides. Now, these stories are remarkably similar. A helicopter company charges tens of thousands of dollars for a ride; insurance pays only a fraction; the patient gets billed for the rest. NPR's Alison Kodjak brings us one of those stories. And a warning - there are graphic descriptions of a wound.
ALISON KODJAK, BYLINE: Dr. Naveed Khan is a radiologist in the Dallas suburbs, and his life has changed in a lot of ways since he lost his left arm in December, like how he cares for his 1-year-old son.
NAVEED KHAN: How do I hold him while he's crying and at the same time heat up his bottle?
KODJAK: He now depends on his wife to help him dress.
KHAN: She helps me put on things in the morning when I get going. I mean, she's there at night when I need her.
KODJAK: And there's at least one thing that he doesn't miss.
KHAN: I haven't changed a poopy diaper since I got home from the hospital (laughter). That used to be my job - all the poopy diapers.
KODJAK: Khan and his wife, Ayesha, have three preschool-age kids. They live a typically busy life of two professionals with young children.
UNIDENTIFIED PERSON #1: Come on, hurry, eat it (foreign language spoken).
UNIDENTIFIED CHILD #1: But I'm not hungry right now.
KODJAK: When I visit them in their suburban Dallas home, they've just picked up the kids from day care and are feeding them takeout.
UNIDENTIFIED PERSON #2: You want more? Yeah. No, oh, don't spit.
UNIDENTIFIED CHILD #2: (Laughter).
KODJAK: We sit down and talk about his accident. He had gone to Wichita Falls with a friend to ride ATVs. It's about two hours from Dallas near the Oklahoma border. They went riding along the banks of the Red River. And then his friend told him to take the wheel.
KHAN: And he said, all right, you get in the driver's seat because at that point he had mostly been doing the driving.
KODJAK: Khan did a few circles in the sand and then turned back, and the ATV tipped over.
KHAN: In a second, I was on my side, realized that I couldn't move my arm much.
KODJAK: He worked his way out of his seatbelt and took off his jacket.
KHAN: And when I looked down on my arm, I had about a 6-inch-wide exposed flesh gap that I could see below on my forearm. And I could see muscle. I could see the fat. I could see the skin, and blood was pooling around it.
KODJAK: Khan and his friend are both doctors, and they could see that this was serious, but they were pretty far from the road. So they made a tourniquet from his jacket. Then they struggled to get the ATV upright and on the trail again.
KHAN: I slumped into the side, and he just let it rip. And then we just went as fast as we could. He was just gunning it.
KODJAK: When they reached the road, he got into an ambulance.
(SOUNDBITE OF AMBULANCE SIREN)
KODJAK: The ambulance brought Khan here to the emergency department at the United Regional Health Care System in Wichita Falls. They told him that they couldn't treat him here, and he would need to go to the trauma center in Fort Worth by helicopter.
KHAN: They took one look at it and said that is one of the worst forearm injuries we've ever seen.
KODJAK: Khan, by now groggy from painkillers, asked the doctor how much it would cost.
KHAN: And he said, I have no idea. And I think they told either my friend or someone that, look; he needs to stop asking questions. He needs to get on that helicopter. He doesn't realize how serious this injury is.
KODJAK: The helicopter brought him to the John Peter Smith Hospital in Fort Worth. Rajesh Gandhi, the head of trauma surgery there, shows me where Khan landed.
RAJESH GANDHI: This is our helicopter pad.
KODJAK: Gandhi says in Khan's case, speed was important because the blood flow to his arm was compromised.
GANDHI: If there's no blood going, that means there's no oxygen. There's no oxygen, that means those cells are going to die.
KODJAK: Khan spent three weeks at JPS hospital. He had eight surgeries to try to save his arm. But in the end, they weren't successful. His arm was amputated in December. Still, his doctor says time was crucial to any hope of saving it, and the helicopter added to that hope, but it came with a price. The helicopter company, Air Evac Lifeteam, called Khan just three days after the flight while he was still lying in his hospital bed.
KHAN: They said it was going to cost over $50,000, and said, yeah, how do you want to pay for it?
KODJAK: The bill was $56,000. Khan's insurance paid $12,000, so he still owes $44,000. So how did Air Evac Lifeteam come up with that price? The company wouldn't do a recorded interview, so I asked Rick Sherlock. He's the executive director of the Association of Air Medical Services. He says the average cost for an air ambulance ride is $10,200.
RICK SHERLOCK: But that number needs to be placed in context. You know, it costs roughly $3 million a year to run an air medical base.
KODJAK: He says Medicare, which accounts for about half the air ambulance rides, pays only about $6,500, and Medicaid pays even less.
SHERLOCK: You have to solve the problem of the vast under-reimbursement.
KODJAK: So Air Evac Lifeteam and other medevac companies try to get people like Khan who have insurance and maybe a good income to pay the difference. But Dr. Ira Blumen says those helicopter rides don't need to cost that much.
IRA BLUMEN: I think overall we have too many helicopters serving the continental United States.
KODJAK: Blumen is an ER doctor and runs the air ambulance program at the University of Chicago, and he tracks the industry more closely than just about anyone. He says the number of air ambulances grew dramatically in the early 2000s when private equity companies started buying them up and expanding.
BLUMEN: It's true that what Medicare reimburses is below that range of $10,000 to $12,000 that it would cost per flight. But if they were doing more flights because there were fewer aircraft, then there would be a better ratio for the reimbursement.
KODJAK: He says that in the 1990s, helicopters generally flew more than 500 patients a year. At that rate, each ride today would cost less than $6,000. When I explain all this to Naveed Khan, he's angry.
KHAN: It's random. It's arbitrary. It's whatever price they want to set. And to put that on a person who's already been through what I've been through, it's - I hate to say it, but it's cruel.
KODJAK: Alison Kodjak, NPR News.
KELLY: And if you have a medical bill you want to share with us and with our partners at Kaiser Health News, you can do that. You can do it online at NPR's Shots blog. Transcript provided by NPR, Copyright NPR.