To lower costs and improve billing for patients who need ground ambulance services, federal lawmakers should ban surprise bills, limit patient cost-sharing and make bills easier to understand, according to a committee formed by Congress to explore how to tackle these issues.
Each year, an estimated 3 million privately insured Americans are taken to emergency rooms by ground ambulances, according to the Petersen-KFF Health System Tracker. Of those trips, more than half are considered out of network by insurance companies, often resulting in surprise bills to the tune of thousands of dollars.
Many factors influence those costs. Ground ambulance services may be operated by state or local agencies, such as fire departments or emergency medical services, hospitals, volunteers or private equity firms. Ambulances that respond to the scene may not be covered by an individual’s health insurance, and many people are unable to determine if the service is in-network or out-of-network in the midst of a medical emergency.
Lawmakers in 14 states have already passed laws to protect consumers from surprise bills if they need a ground ambulance. In 2021, the No Surprises Act included patient protections for air ambulance care, but left out provisions for ground ambulances because the nation’s system was too complex for Congress to address at the time. Instead, members of Congress created the Ground Ambulance and Patient Billing Advisory Committee to research and make recommendations for lawmakers to consider in future legislation.
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The 17-member committee, which met over six months, represented paramedics, emergency medical services, emergency physicians, patient advocates, state insurance regulators and ambulance companies. They primarily focused on emergency services, but also attempted to address non-emergent services, such as transporting a hospitalized heart patient to another facility for cardiac surgery. Ultimately, they crafted dozens of recommendations for 15 different issue areas. Along with how and what a patient should be billed, recommendations also included guaranteeing payment for ambulance crews and creating a better system for billing disputes.
“Many of the things we’re voting on today are intertwined,” said Shawn Baird, committee member and former president of the American Ambulance Association, who emphasized that many of the committee’s recommendations would not work well if broken apart and packaged as individual pieces of legislation.
The public is invited to comment on what Congress should do to address ground ambulance billing through Nov. 15. The committee will deliver a report with all recommendations, distinguishing those that received a majority vote of support, to Congress in early 2024.
“It’s not clear how much room there is on the legislative agenda” to take up the committee’s recommendations, said Jack Hoadley, a research professor emeritus at Georgetown University’s Public Policy Institute. But there is plenty of fodder for new laws that would affect millions of Americans, he said.
“I like to think Congress could take this up and it could be relatively non-controversial in that most of the recommendations were unanimous or nearly unanimous,” Hoadley said.
Here are some highlights from this week’s proceedings.
Protect patients from balance billing
The committee voted to protect patients from balance billing, urging Congress to mandate health insurance plans to provide coverage for emergency transport, including out-of-network ambulance care. Members reached a “general consensus that we could keep patients out of the middle,” said Asbel Montes, who chaired the committee.
This would also include transportation on an ambulance from one hospital to another for necessary care – an increasing need amid hospital mergers that consolidate specialty services, such as maternal care or cardiac surgeries, onto specific campuses.
“Usually, people go to the closest hospital, but now you need to be going to the facility that has the coverage you need,” said Patricia Kelmar, senior director for health care campaigns at U.S. Public Interest Research Group. In an emergency, patients cannot be expected to make that call.
Limit copays for ground ambulance rides
The committee also recommended limiting patient copays to $100 for a ground ambulance ride, or 10 percent of what insurance pays for out-of-network ambulance services. Adam Beck with the lobbying group America’s Health Insurance Plans warned that this recommendation could potentially create cheaper out-of-network cost-sharing for patients compared to services covered by their insurance.
But according to Kelmar, having a firm dollar amount gives many people peace of mind and makes it easier for them to call an ambulance when they need it, rather than gamble with their finances and health.
“It’s poor public health to have question marks in people’s head about the cost of calling an ambulance,” Kelmar said during a call with reporters after the two-day meeting ended.
Make ambulance bills easier to understand
For people who have needed to take an ambulance, the fear of what that ride might cost often sets in almost immediately. Patient bills often are very confusing, Kelmar said. But that could change if Congress agrees with the committee’s proposal for clearer, more streamlined billing language. This language would include whether the bill reflects the patient’s insurance coverage, ways for the patient to dispute the charges and ways to report an illegal surprise bill.
“It’s really hard to understand what’s a bill, what’s not a bill, particularly if you’re still recovering or in the hospital or maybe you’re on medication that makes you groggy,” she said.
Guarantee payment to ambulance crews
Ground ambulance services are not always compensated. An ambulance crew may administer medical care on the scene, such as Narcan for an opioid overdose or insulin for a diabetic patient. If the patient then no longer needs to go to a hospital, crews are not reimbursed for the potentially life-saving care they delivered. If they do transport the patient to an emergency room, they may not receive health insurance information from the hospital. That lack of transparency adds costs to companies that may already be cash-strapped, Baird said. Those costs often get passed back to patients in the form of surprise bills or higher insurance premiums.
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The committee recommended that Congress explore guaranteed payment to ambulance crews so that they can recoup the cost of care.
“EMS is the only sector of health care where local communities have a public process to determine exactly what kind of service they’re going to get and how much it’s going to cost,” Baird said.
Avoid independent dispute resolution
Patients and ambulatory care providers have said they want to remove patients from disagreements on payments between health insurance companies and ground ambulance companies. Under the No Surprises Act, the independent dispute resolution process was intended to do that. But in reality, these disputes have languished for months in what health economist Loren Adler described as “a huge bureaucratic boondoggle.”
Committee members pointed out that using the independent dispute resolution process for ground ambulance services would further burden administrative workers already overwhelmed with disagreements over health care costs.
