BY Julie Speed

  After Medicare denied most claims for EMS service, Pafford Ambulance Service packed up and went home.
Jamie Pafford-Gresham of Pafford Ambulance Service said repercussions of the Balanced Budget Act of 1997 were not the reason the 32-year old family business left the Mississippi Delta.
  "We left because of the incompetence of United Health Care, the Medicare carrier in Mississippi, and its inability to process claims correctly," said Pafford-Gresham, who is also on the board of directors for the American Ambulance Association. "At one point, we had a 100% denial rate and averaged 70% denials. It was very rare to get a claim paid in Mississippi, which is the worst state in the nation to process claims. We provide ambulance service in two other states, Louisiana and Arkansas, where we haven't had a problem."
  Pafford Ambulance Service, founded in 1967 in Hermitage, Ark., transferred services in Washington, Coahoma and Tallahatchie counties in the Mississippi Delta to another emergency medical service company that could not be reached for this story.
  Like Pafford Ambulance Service, other emergency medical service providers in Mississippi are facing problems related to unpaid Medicare claims.
  "The effects are devastating," said Steve Delahousey, director of operations for the Gulf Coast region of AMR, the nation's largest emergency medical service provider and a member of the state's Emergency Medical Services Advisory Council. "At least 18 counties in Mississippi have either had to shut down ambulance service or reduce their level of service due to the reimbursement practices of Medicare."
  In Mississippi, 60% of AMR's revenue is derived from Medicare.  In 1995, less than 2% of all EMS claims were denied by Medicare. This year, 50% of all claims were denied. However, administrative law judges overturned 86% of all emergency claims this year. But the appeals process takes about two years to reach the ALJ level, he said.
  "We have not had much success in having the cases overturned at the review board or fair hearing level, but at the ALJ level, the cases are overwhelmingly overturned in favor of the ambulance providers," he said.
  Because there are no Medicare HMOs in Mississippi, United Health Care in Jackson is the designated HCFA representative in charge of processing Medicare claims. Calls to United Health Care were not returned for this story.
  "Evidently, the carrier is reading a different set of rules than we are," said Pafford-Gresham. "If there's a 3 a.m. call from someone with chest pains and a shortness of breath, Medicare says that if this person is sitting up in a chair using a phone, then they can ride in a car. That's not how it works. We're an advanced life support unit so we can help stop some of the things that are going to happen before they do. What it's going to take is people reading about this in publications and asking themselves, "What if this happened to my mother?" Each county is going to have to take a stance and recognize that someone is wrong with the system."
  Before Pafford Ambulance Service pulled out of the Mississippi Delta, Delahousey, Pafford-Gresham and a representative of another service in south Mississippi - combined, they represented 70% of all emergency medical service vehicles in the state - traveled to Washington, D.C. where Senator Trent Lott arranged a meeting with HCFA officials.
  "As a result of a meeting with HCFA, we received a letter that, among other issues, said, yes, the carrier has to look at appeals results and review their policies and practices as part of their policy," said Delahousey. "We thought the situation would improve, but it hasn't. The tragedy is that Mississippi has come so far in the last couple of years by putting a trauma service system in place. But that really doesn't matter if we can't get the patients there in a timely fashion with good, high standards of acre in a pre-hospital setting. Ultimately, patients suffer the most."