Surprise Medical Bills and Ground Ambulances

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I knew I shouldn’t put off facing the stack of medical bills piling up on my dining room table any longer. They’d started to arrive even before I got home after five weeks in the hospital, a mountain amid mounds of other medical paperwork and get-well cards.

My saga started in mid-March, when I had a cough that wouldn’t go away and a mild fever spiked to 103° F. I went to the emergency room, where I suddenly became unable to breathe. I was put on a ventilator for 10 days and spent a few weeks in an intensive care unit, where I slowly recovered from the flu and pneumonia. (Though my symptoms were similar to those of COVID-19 and this happened during the pandemic’s first wave last year, I never tested positive for the coronavirus.) After a stint in a rehabilitation hospital and physical therapy at home, I felt much stronger and ready to tackle that pile of bills.

So one sunny afternoon last June, I sat on my deck and ripped open each long white business envelope. Some were second notices warning me to pay up. But I was fortunate: I have good insurance through my employer. Even though the charges for my care were about $330,000, I owed only a little over $3,100 out of my own pocket.

Aetna, my insurer, covered all my expenses beyond copays and coinsurance after I met my $1,500 deductible. Except for one bill: $3,000 for an ambulance ride from my local hospital to a larger medical center that my doctors thought was better equipped to treat me. The letter from the ambulance provider, American Medical Response, said my insurer paid only $1,200 because AMR didn’t have a contract with Aetna to provide emergency services. The remaining $1,800 was my responsibility.

I was shocked. I was sedated before my ambulance ride, so I have no memory of the 47-mile trip. There’s no way I could have checked in advance to find out whether the ambulance provider took my insurance—not that I would have wanted to in that moment.

In retrospect, I shouldn’t have been surprised. As a reporter at Consumer Reports, I’ve covered surprise medical bills and talked to dozens of people with similar experiences. I knew that out-of-network bills are most common in emergencies where patients have little or no control over who provides their care.

The issue of surprise medical bills took on more urgency with the COVID-19 pandemic, and in December, Congress passed a major COVID-19 relief and spending package. It included the No Surprises Act, which bans surprise medical bills in emergencies as well as those from out-of-network providers who treat you at an in-network medical facility. The changes take effect in January 2022. The ban even extends to air ambulances, which often don’t participate in insurance plans and can result in medical bills reaching tens of thousands of dollars.

But the law had one glaring omission: It doesn’t apply to ground ambulances, even though they are one of the most common sources of out-of-network bills and can leave consumers on the hook for hundreds or thousands of dollars.

“Congress fell short,” says Karan Chhabra, MD, a surgical resident at Brigham and Women’s Hospital in Boston. Chhabra was lead author of research published last year that found that 79 percent of all ground ambulance rides could result in an out-of-network bill. The study was based on a large national health insurer’s claims data from 2013 to 2017. Another study, published in 2019, found that 86 percent of ambulance rides to hospital emergency departments resulted in an out-of-network bill for patients with private insurance, a far higher rate than from other physician specialists encountered in an ER visit, including ER doctors and anesthesiologists.

Why Congress Didn’t Take On Ambulance Providers

Why would lawmakers leave a loophole for ground ambulances? Because cracking down on them is complicated, says Chuck Bell, programs director at Consumer Reports, which has long advocated for consumer protections against surprise medical bills.

One main factor: The ownership of ambulance services is extremely fragmented. Almost half are run by local governments, often via police or fire departments and partly funded by taxpayers, according to a RAND Corporation analysis in a 2019 report (PDF) for the Centers for Medicare & Medicaid Services. The rest are for-profit or not-for-profit companies that towns, municipalities, and hospitals contract with for ambulance services.

Federal lawmakers are loath to pressure local governments to spend more on ambulances or to raise taxes to cover the revenue they’d lose if they couldn’t collect as much for those services, says Loren Adler, associate director of the USC-Brookings Schaeffer Initiative for Health Policy, who has studied surprise medical bills.

There’s another factor, too: Over the past decade, private equity investors have moved into the ambulance business, and today about 10 percent of ambulance providers are owned by private equity companies. These companies saw a profit opportunity, given that they could go after patients for charges that insurers were unwilling to cover, Adler says. The biggest player is KKR, which happens to own AMR, the ambulance company that sent me a surprise medical bill.

In a statement, AMR said that it tries to keep the patient out of the middle and actively works with private insurers to negotiate reasonable in-network rates but that private insurers frequently decline to enter into contracts.

While private equity-owned firms may be more aggressive than municipalities when it comes to billing and debt collection, Adler says that the entire ambulance industry is under financial pressure and that both government-run and private providers send patients surprise bills.

Surprise bills happen when an insurer covers only part of a healthcare provider’s charges because the provider doesn’t participate in the insurer’s plan. In a practice known as balance billing, the patient gets charged for the rest—something that won’t be allowed under the No Surprises Act. Ambulance companies aren’t motivated to contract with insurers because they know that “if you need an ambulance, you can’t shop around,” Adler says. Consumers “are effectively a captive patient base.”

For their part, ambulance companies say insurers don’t reimburse well enough for them to be in-network providers. Ambulances are costly to operate because they must be available 24/7, 365 days a year with a skilled medical crew at the ready, says Rob Lawrence, communications committee chair at the American Ambulance Association. And if an ambulance is called and treats someone at the scene but doesn’t take that person to the hospital, an insurer typically won’t reimburse the ambulance provider, says Lawrence, who estimates that about 25 percent of ambulance calls don’t result in a hospitalization.

The pandemic has exacerbated the ambulance industry’s financial problems. Ambulance providers say they are being squeezed by the drop in demand for non-emergency transports as fear of getting COVID-19 has led people to put off medical care. And worries about COVID-19 exposure have increased reluctance to go to the hospital even if people get sick and call an ambulance.

Healthcare experts say the impact of surprise bills from ambulance rides may go beyond financial risk for patients. “If patients are reluctant to call an ambulance and go to a hospital when they are ill, that can have consequences,” Chhabra says. “That’s why we need to protect patients from these kinds of bills.”

Consumers Taken for a Ride

CR has collected hundreds of stories about surprise medical bills from patients. Ambulance billing problems frequently come up.

A common complaint is that the bill seems out of line with the service provided. Alan Hill of Alpharetta, Ga., called an ambulance in December 2018 when, after dinner out on a business trip to Honolulu, he felt feverish and sweaty and worried he was having a heart attack. But after the paramedics arrived, he told them he felt better. They thought he should go to the hospital anyway, for observation. A few months later, Hill learned that his insurer paid $750 of the $1,445 bill and that he owed the almost $700 balance because the ambulance company was out of network. “For a 10-minute ride. What a rip-off!” says Hill, who says he paid it.

When a family member of Susan H. (her last name is being withheld to protect her family’s privacy) needed help for a mental health issue at an ER near where they live in Chicago, she was told that an ambulance would need to take him to an inpatient psychiatric hospital 25 miles away. Susan wanted to drive him instead because it was voluntary admission not requiring medical care, but was told no.

She later received a bill for $2,700, but the insurer covered only around $500. “The ambulance bill was by far the biggest bill we received for the entire hospitalization,” she says. After months of calls between the insurer and ambulance provider, Susan was worried the bill would go to collections. She was able to negotiate a $900 discount with the ambulance company but still paid $1,300. “It is extremely frustrating because we had absolutely no choice but to use this service,” she says.

Some people are so afraid of ambulance bills they’d rather take an Uber. Katie Terry of Lawrence, Kan., says she has a high-deductible health plan and can’t afford to go to the doctor, let alone take an ambulance. “I have it written in my medical ID in my phone to please not call an ambulance unless I will definitely die without one,” she says. “If I have the ability to call an Uber instead, I will do it.”

“The No Surprises Act is a huge victory for patients, but Congress and the states still need to fix this problem with ambulance bills,” says Bell at CR. “If we’re protecting patients from surprise billing inside the ER, what about protecting them for the ambulance trip that brings them there?”

It may still happen: The No Surprises Act called for an advisory committee with government officials, consumer advocates, insurers, and ambulance providers to study how consumers could be better protected from surprise bills for ground ambulances.

Medicare and Medicaid, which already ban balance billing on ambulance services, may also play a role. The two federal health insurance programs are reviewing their payment rates for ground ambulances, which haven’t changed since 2002. If they boost rates, that could spur insurers to pay more and ease pressure on ambulance service providers to bill patients with private insurance more.

How to Fight a Surprise Ambulance Bill

For now, the onus is still on consumers to deal with out-of-network ambulance bills. Here’s how:

Ask questions. In an emergency, there is usually no time to see whether an ambulance is in your network. But many ambulance calls are for non-emergencies, such as when a hospital patient is sent to a rehab facility. Yet 52 percent of non-emergency ground ambulance transports still involve potential surprise bills, according to Chhabra’s study. In some cases, this may happen because in some communities—such as Houston, where city-run ambulances don't contract with private health insurance plans—local ambulance services are all out of network. But often, people just don’t think to ask, Chhabra says. If it’s a non-emergency, phone your insurer and ask whether there’s an in-network ambulance you can use.

The CARES Act may provide some protection. Healthcare providers, including ambulance services, that took money from the federal Provider Relief Fund created by the March 2020 CARES Act aren’t allowed to balance bill patients for care if they have a suspected or confirmed case of COVID-19. You can look up healthcare providers who took relief funds on the Centers for Disease Control and Prevention website. If that’s the case in your situation, use the information if you have to dispute a bill.

Check your state laws. A few states have passed laws against surprise medical bills that include restrictions on ground ambulance billing.

In January, Ohio enacted a law banning surprise medical bills starting in 2022 that mirrors the No Surprises Act but includes ground ambulances. In New York, out-of-network providers can’t bill insured patients more than in-network rates in emergency situations, including for ground ambulances though not for transports between facilities. In Colorado, a 2019 law that went into effect last year bans private ambulances from balance billing patients, though public ambulances funded with taxpayer dollars are exempt. Maryland has a similar balance billing law that applies to ground ambulance services, but only those operated by local governments or volunteer fire departments and rescue squads.

State laws have other limits, too. They usually don’t extend to self-funded employer-sponsored plans, which is where many people get their health insurance coverage. Contact your state’s department of insurance to find out how it works in your state, and your human resources department to find out whether your plan is covered.

Consider an ambulance service membership. Some ambulance organizations offer membership programs. You pay an annual fee, which may be $30 to $75 per year for an individual. If you call an ambulance, the company still bills your insurance but you never have any out-of-pocket costs. Most people probably don’t need such a program, but it may make sense if you have an underlying condition that could trigger a regular need for an ambulance, such as epilepsy. If you consider one, make sure you live in that provider’s service area. And if you live in an area with several providers, make sure anyone who may be calling an ambulance for you knows about your membership.

Negotiate the bill. If you get stuck with an out-of-network bill, ask your insurer to review the claim and cover more of the rest of the bill. If a phone call doesn’t resolve the issue, appeal. This guide from the Patient Advocate Foundation provides step-by-step directions. If your insurer doesn’t budge, contact the ambulance company and ask whether it can lower the charge or offer a payment plan. Also report the problem to your state insurance regulator or state attorney general, and mention that in your insurance appeal letter and in your negotiations with the ambulance company.

Talking to my insurer did the trick. I put off dealing with my ambulance bill for so long I got a notice saying my bill would be turned over to a debt collector. I contacted my insurer, Aetna, and the customer service representative I spoke with said she would submit my claim for review again. The rep was very helpful, and during the same call, she contacted the ambulance provider with me on the line and asked them to put the bill on hold for 30 days while Aetna reprocessed the claim. AMR agreed.

A few weeks later, I got a notice that Aetna paid AMR an additional $1,500, covering all but $283 of the original $3,000 bill. Aetna warned me that AMR could still bill me for that balance. Turns out they were right. When I contacted AMR, it said that my case was still under review but that if my insurance didn’t pay the $283, I’d get a bill for the remainder.