51% Emergency Ground Ambulance Rides Result in Surprise Billing

Ground ambulance rides, which were excluded from the No Surprises Act, continue to contribute to surprise billing in the US, a Peterson-Kaiser Family Foundation brief found.

Experts analyzed 2018 large employer health plan claims data in order to assess the rate of surprise billing for ground ambulance rides. They also included data from National Hospital Ambulatory Medical Care Survey from the same year which encompassed data on ambulance rides that had an emergency department as their destination.

Slightly more than half of the emergency ground ambulance rides (51 percent) and four out of ten non-emergency ground ambulance rides resulted in an out-of-network charge. Such charges often lead to surprise bills for patients.

Overall, the researchers estimated that approximately 1.5 million privately insured patients annually may receive a surprise medical bill. Ten percent of emergency visits for privately-insured patients involve a ground ambulance.

The rate of ground ambulance charges could be more frequent based on the patient’s geographical placement. For patients in Washington, California, Florida, Colorado, Texas, Illinois, and Wisconsin, more than 66 percent of emergency ambulance rides could result in a surprise bill due to an out-of-network charge.

The emergency ground ambulance transportation came from three main sources: the fire department, private and non-hospital organizations, and governmental or non-fire departments.

Both state and local governments had addressed the issue of surprise billing in different ways regarding ambulance providers and insurers.

For example, some areas do not bill county residents for ambulance rides. The entire bill goes to private insurance, Medicare, or Medicaid depending on the patient’s coverage. However, this policy does not extend to non-residents who use the service.

Elsewhere, areas have policies that are plan type-specific. Members of health maintenance organizations, preferred provider organizations, and exclusive provider organizations are protected from covering out-of-network costs.

Some regions sought to allow providers and payers to settle their own out-of-network emergency ambulance payments and regulated that process to create a clear dispute resolution process, specifically naming ground ambulatory services as included in such policies. This strategy is similar to the No Surprises Act’s approach to other surprise billing issues.

The No Surprises Act covered much of surprise billing but left a gap for ground ambulatory services, ostensibly in order to return to the subject in later regulatory action. In Section 117, the law directed the Departments of Labor, HHS, and the Treasury to investigate the issue and report back to Congress with recommendations.

"The regulation and delivery of ground ambulance services could present complexities beyond those involved in preventing other surprise medical bills. Yet, from the perspective of patients, ambulance rides are exactly the kinds of situations where they feel powerless to avoid surprise bills,” the researchers concluded.

Researchers have suggested that federal policies on surprise billing could have impacts on private payers.

In 2020, a study of Aetna, Humana, and UnitedHealthcare found that surprise billing policies could lead to lower payments and lower premiums for private payers. However, researchers noted that these results could be isolated to the three payers that the study addressed.

Industrywide, there are at least four potential impacts that this law could have when it goes into effect, according to a previous Kaiser Family Foundation issue brief.

The researchers expressed doubts about whether the complaint process as established by the new law would be effective, as it had proven fairly underutilized in other contexts such as the Affordable Care Act marketplace.

The law’s results could also depend on which of the two billing dispute resolution processes introduced payers and providers favor. If they lean more frequently into independent dispute resolution, researchers indicated that this process could impact costs and timeframes of dispute resolution.

Employer-sponsored health plans have to contract with independent review organizations, which could have unknown consequences for payers.

Lastly, the bill will require data collection for the independent dispute review process, which could boost the administrative burden.

While the results of the No Surprise Billing Act will remain unknown until after the law goes into effect, the researchers who studied ground ambulance rides made it clear that surprise bills for ground ambulance rides continue to put patients at risk of surprise billing and that it will be a complex issue to resolve in the regulatory space.