Patients still have no protection against surprise ambulance bills. And there’s no solution in sight

One night in November 2021, 11 weeks into her pregnancy, Carolyn Provine started bleeding — a lot. When she passed out, her wife and mother-in-law called an ambulance and drove 21 miles to the hospital for an emergency surgery. But the hemorrhaging, and miscarriage, no longer were Provine’s only concerns.

“My first thought was, ‘Wait, is there some way for me not to take an ambulance?’” said Provine, 26, a reading specialist in Vermont. “I had had one in college for something that wasn’t life-threatening at all” — a dislocated kneecap, she said — “and my mom had been hit with this pretty big bill.”

Provine had health insurance. But like a vast majority of those who take an ambulance for an emergency, the ride was out of her insurance company’s network. She paid $516.90 — on the low end of the $500 to $750 range for average charges, depending on who owns the ambulance service.

In a cruel twist, ground ambulances were excluded from the federal law that banned most types of surprise medical bills starting in 2022 — even though roughly 85% of all emergency ambulance rides are out-of-network, like Provine’s. And there is no traction in Congress to craft a solution anytime soon. Instead, the federal law known as the No Surprises Act created an ambulance advisory committee, which will study patient billing more and make formal recommendations. But even that committee is off to a shaky start: Its inaugural meeting in January was postponed and is now expected to meet for the first time in March.

“We know that patients continue to get an out-of-network ambulance bill that’s expensive and isn’t covered by their insurance, and they have no recourse and have to pay it. It’s really troubling,” said Patricia Kelmar, a health care director at the consumer advocacy group U.S. PIRG who sits on the federal ambulance advisory committee.

Surprise bills for ambulance trips have been an obvious problem. People don’t shop for most health care services, and that’s most true for patients who are sick, injured, or unconscious while on a gurney in a vehicle. Solving bills in these circumstances has been less obvious, due in part to America’s patchwork system of ambulances.

Local fire departments and municipalities operate a majority of ambulances, according to new research published this year in Health Affairs. Private equity and other publicly traded companies, meanwhile, make up 1 out of 10 ambulances. Some rural ambulances barely see any patients, while those in bigger cities are dispatched at all hours. On top of everything sits differing rules from county and state governments — some of which regulate what ambulances can charge. Federal lawmakers ultimately didn’t want to upend this odd system in the No Surprises Act.

“There was a natural nervousness that this might mess with the applecart a little bit,” said Loren Adler, an associate director of the USC-Brookings Schaeffer Initiative for Health Policy, who also sits on the ambulance billing advisory committee.

Some states have taken matters into their own hands, to the extent they can. Ten states have outlawed surprise bills for ground ambulances, according to a recent report authored by Kelmar of U.S. PIRG. But those protections only apply to people who are insured in a plan regulated by that state. Most people who get health insurance through their jobs are enrolled in self-insured plans, which are exempt from state insurance laws.

James Safin found this out the hard way this past November while working at his employer in Illinois, which is one of the 10 states that bans or limits surprise ambulance bills. The 34-year-old felt extremely dizzy and disoriented and called for an ambulance, which was operated by the village of Westchester. After clearing a checkup and tests at a nearby hospital, he went home.

In December, Safin wanted to know how much he owed for the ambulance. He gets insurance through a self-insured employer. The employer’s third-party administrator, Aetna’s Meritain Health, originally said insurance would pay almost $500 for the ambulance, and Safin would owe a separate $122.89, according to documents shared with STAT. But a few weeks later, he received a bill in the mail from Westchester for almost $2,300.

“I was taken aback,” Safin said. “It was very surprising and alarming. It contradicted what I had been told.”

After several weeks of inquiries from STAT, Westchester’s fire department, which runs the ambulance service that took Safin, and a Westchester attorney did not formally respond. A spokesperson for CVS Health, which owns Aetna and Meritain Health, sent a statement: “The claim for the ambulance service that Mr. Safin needed was administered correctly.” Neither side would even confirm whether they had negotiated with each other. Safin ultimately contacted his company’s human resources department, which has since told him he would not owe the $2,300 and is working to settle the bill.

More than 100 million other Americans in self-insured health plans face the same situation if they take an ambulance today.

“You need a federal solution here,” Adler said. “It’s pretty unfair to just leave people in the lurch.”

There’s no consensus on what that solution should be. The arbitration process created by the No Surprises Act for other medical bills has been a mess so far — doctors, other provider groups, and insurers have been entangled in a Gordian knot of unsettled claims, and a flurry of lawsuits led by doctors is muddying how arbiters should make final judgments. Experts agree jamming ambulance claims into the same process isn’t feasible.

“The fundamental policy question is, how do you design an arbitration system that encourages [the two sides] to settle?” said Ben Chartock, a health economist at Bentley University who has studied surprise bills for roughly a decade.

Policy experts have also floated a simpler approach: paying all out-of-network ambulance bills based on percentages of what Medicare would pay. For 2023, Medicare pays a base rate of $266 per ambulance ride, and that base rate could fluctuate higher based on the level of care someone needs, geography, and other add-on payments. Medicare also pays $8.54 per mile traveled. All in, Medicare pays around $500 for the average ambulance ride.

Ambulances, like other providers, argue Medicare underpays them. Previous government studies have suggested that’s not true in all cases. To that end, Medicare is in the middle of a multi-year project to collect cost and revenue data from ambulance providers.

The foundational, intractable problem ultimately is the same one that has defined all surprise billing disputes: The two negotiating parties don’t like each other very much.

“We want to take the patient out of the middle,” said Maria Bianchi, CEO of the American Ambulance Association. “The problem comes down to inadequate reimbursement by a lot of the insurers.” Bianchi added that insurers often pay little to no attention to smaller ambulance companies that have a relatively low amount of claims. America’s Health Insurance Plans, which represents insurers in Washington, did not provide a formal position on ground ambulance surprise bills.

James Gelfand, president of the ERISA Industry Committee, which lobbies on behalf of large self-insured employers, believes ambulances are using their complicated structure as an excuse to get off the hook for deliberate business decisions. He testified twice in front of Congress in 2019, demanding lawmakers include ground ambulances, to no avail. He said the problems have only gotten worse, and employers often aren’t notified when out-of-network bills are sent to their workers.

“Because the balance bill can be so devastating for patients, many times a group health plan will simply pay it even though they’re not under any obligation to do so,” Gelfand told STAT. “It’s great for an individual patient, but it’s bad for the plan. And it’s also bad for the markets because it encourages this behavior.”

“It doesn’t make sense to protect someone at the hospital, but not on the way there,” he added.

For now, patients’ fate rests with the federal advisory committee. The federal government did not respond to questions about the panel’s agenda. The committee has six months after the first meeting to write a report with recommendations — meaning the earliest anything will come out is later this fall. In the meantime, Congress has no plans of acting, either.

“I don’t think there’s going to be surprise [billing] legislation this year, because, frankly, my office and a few others drove it last time,” Sen. Bill Cassidy (R-La.), the new ranking member of a key Senate health committee, told STAT earlier this month. “We’re not currently engaged in that issue, so I don’t see others picking up the mantle.”

Patients who get an unexpected ambulance bill don’t have many protections, but they can still fight back, consumer advocates say. They should start by appealing with the insurance company and ambulance provider. The appeals process is often intimidating and time-intensive — creating an extra burden for people who are recovering from a traumatic health episode — but persistence can often force the two sides to come to an agreement.

“It’s worth doing for patients, if there’s no other option,” said Caitlin Donovan, a senior director at the National Patient Advocate Foundation. If appealing hits a stalemate, patients should rope in their HR and benefits managers. Donovan said she’s also heard of people paying for ambulance memberships to avoid any billing hassles.

Provine is fully recovered. Even though she and her wife didn’t go into debt paying the ambulance bill, the experience made a bad impression. It’s the type of thing that could make patients second-guess whether they call an ambulance at all, and one she believes adds more stress to an already stressful situation.

“Nobody is in a position to turn down an ambulance by the time they arrive,” Provine said. “When you’re in an emergency, you may not even be sharp enough. It’s not like, ‘Let me come out of my anemia haze for a second to Google ambulance companies.’ That’s not how it works.”

Sarah Owermohle contributed reporting.