A Broken Emergency Medical System (EMS) Means Lots Of Surprise Bills

What goes through your mind when you hear an ambulance siren? Until last year I used to think help is on the way! Now, the first thoughts that pop in my head are surprise bills and how broken the EMS system (Emergency Medical System) is in the US.

Why? My perspective on ambulances changed completely when I had to call 911 for our daughter last year. I had no idea that a phone call to save her life would trigger an 11-month long $3,532 surprise billing battle.

If you read my article on the surprising cost of calling an ambulance, you may never look at ambulances the same way again either. Thankfully, I was able to fight back and resolve our surprise ambulance bill.

But, I also learned that our EMS system is in trouble. And that means lives and bank accounts are at stake. What's scary is that most people have no idea how bad things have gotten. I certainly wasn't aware of how unregulated things are until I went through this 11-month journey.

The Final Outcome Of My Surprise Ambulance Bill

Fighting a $3,532 balance bill with AMR (ambulance company) wasn't an easy journey. It was stressful as hell! I lost sleep, got stress hives, and my lower back flared up in pain.

But, in the end, I got a decent resolution. The experience also got me fired up enough to write three articles about it. I hope my efforts to raise awareness will somehow make a difference, even a small one.

What was the final outcome of my surprise ambulance bill? Well, the wheels started to get in motion when I got news from the Egregious Billing Department of my insurance company (UHC). Initially, I thought I was screwed because the notice I received started with, “We were not successful in obtaining a negotiated agreement with the ambulance provider on the pricing for the above case.

But, the notice continued with, “We have made the decision to allow the claim at the full billed charge. Benefits are subject to the terms and provisions of your plan, which include but are not limited to deductible and coinsurance provisions.

What does that mean in plain English?

In the end, AMR still refused to accept contracted rates from my insurance company. My insurance company tried to negotiate the pricing of my claim but AMR refused. Fortunately for me, my insurance company “caved” and decided to re-process my claim a different way.

This time, instead of applying discounted in-network rates to my out-of-network claim, they used AMR's non-adjusted rates in full.

Thankfully, I didn't end up having to pay $3,532 to AMR. But I did end up owing a total of $850, or 20% of the original $4250. My insurance paid the rest to AMR. This wasn't a randomly chosen percentage by the way. It was 20% co-insurance, which my insurance plan charges for in-network ambulances, ER care, hospitalizations, etc.

AMR still got all the money they wanted. But, UHC applying AMR's entire charges to the insurance claim is what made the big difference in my out-of-pocket cost. My insurance went from paying AMR only $720 of the $4,250 bill to paying AMR a total of $3,400.

The ambulance ride still cost me $500-600 more than I guesstimated before this whole thing started. But ultimately I'm glad I didn't have to pay all $3,532.

If you want to learn more about all the various steps I went through over the course of 11 months, you can read the details here and learn how to resolve a surprise ambulance bill of your own.

Surprise Billing Legislation And The Broken EMS System

So why did a family like us with a well-rated PPO health insurance plan have to go through such a stressful ambulance billing headache? Insurance companies don't want to pay high rates, many ambulance providers are underfunded, and there's a lack of federal legislation to prevent situations like this.

We all know the US healthcare system is complex and insanely expensive compared to many other countries around the world. But at least the government is making some progress to help protect consumers. For example, The No Surprises Act was enacted in December 2020.

In a nutshell, The No Surprises Act provides consumers with certain federal protections against gaps in coverage for emergency services and others provided by out-of-network clinicians at in-network facilities. So, it will help patients avoid huge surprise bills who are treated by an unknowingly out-of-network doctor at an in-network hospital. Most sections go into effect in January 2022.

But guess what? Although The No Surprises Act includes protections on air ambulance providers (notorious for bills in the tens upon tens of thousands), it excludes ground ambulance providers!

Why were ground ambulances excluded when they affect so many people? The simple answer is “legislators saw adding ambulances as too hard.” Tell me about it! So although we will have protections once we get to a hospital, we're still SOL on protections getting there. This is why some people are too scared to call for an ambulance or want to take an Uber there instead.

There is a small glimmer of hope that the federal government may help resolve surprise bills for ground ambulance down the road, however. A federal commission to study the problem of ground ambulance bills has already been formed. But federal legislation to resolve surprise bills for ground ambulances is probably going to take a long time.

Our government isn't known for efficiency. And they have a lot of research to gather on costs, which has supposedly been hard to come by. Plus, since ground ambulances are not regulated at the federal level, there are vast differences across states, cities, and towns to consider.

There's No Consistency In Ambulance Providers Except The Plethora Of Surprise Bills

What I find fascinating and frustrating is just how different ambulance services are from one zip code to the next. For example, in some places, EMS is provided by firefighters who are cross-trained as paramedics, or by a dedicated division within a local fire department.

In other areas, you'll only find volunteer-based providers. And in the rest, you'll probably find privately owned providers or a combination of provider types. What's interesting is about 25% of ambulance providers are private and a growing number of them are owned by private-equity funds. That doesn't seem like a good thing to me.

What's also scary is rural areas of the US are really in trouble. One-third of them are already at risk of losing ambulance services altogether. Most providers in rural areas are volunteer-based and they're simply running out of funding and volunteers.

A big reason for this is that there is no single federal agency overseeing EMS anymore. Budget cuts under the Reagan administration axed federal oversight and shifted responsibility to states. And unfortunately, 39 states do not consider EMS an essential service, unlike police and fire departments. I was shocked to learn that. According to a CNN video I found, a few of the states that do deem EMS as essential are CT, DE, IN, NC, OR, PA, TN, UT.

So guess what? California, New York, Texas, and Florida (where a lot of you reside) are not on that list!

When a state like CA doesn't consider EMS an essential service, no government entity is responsible for funding ambulance providers. Ambulance companies can still access federal and/or state funding. But it is difficult because the finite amount of funds might be directed elsewhere to whatever services the government deems more important.

Many EMTs Are Underpaid And Lack Benefits

Because of the inconsistency in EMS across locales and the challenges in accessing funding, many ambulance crews are running out of EMTs and volunteers.

Most EMTs are also underpaid and some don't even get health insurance. That just doesn't seem right. The median annual wage for EMTs is only ~$36,650 despite the high risk and stressful job demands. In contrast, the median annual wage for police officers and firefighters is $67,600 and $52,500 respectively.

Broken EMS System Surprise Bills

How Can The EMS System Get Better?

How can we possibly fix such a complex and broken EMS system? John Oliver of Last Week Tonight, who recently highlighted many of the problems with ambulances, has these three recommendations:

  • Officially deem EMS an essential service across all states
  • Create a federal agency to oversee EMS providers nationally
  • Ban surprise billing for out-of-network ground ambulance rides

Sounds like a good plan to me. I certainly hope we see changes like those in our lifetimes. In the meantime, what can we do? Learn what protections (if any) there are in your state and city. For example, some locales have a cap on how much ambulance providers can charge.

You can also spread awareness, write letters to your state representatives and the government, stay healthy, and be prepared for the unexpected.

Related: Get Affordable Life Insurance And Free Quotes Online

Lessons Learned About 911 And EMS Dispatch

In addition, here are some lessons I learned about EMS transport you may find helpful. Hopefully, my experience can help you avoid running into a similar situation.

  • Make sure you thoroughly understand your health insurance coverage for emergency transport and ambulance services. It's best to know your coverage details in advance of needing them.
  • Even if your summary of benefits shows it will process out-of-network emergency transport as in-network, you could still get a huge balance bill.
    • For example, your insurance may process the claim as in-network using contracted rates that the ambulance provider won't accept. Then, the ambulance company sticks you with the difference between their crazy prices and the discounted rates that your insurance used to determine their payment. This is what happened to me.
  • Find out how many EMS providers are in your area and which of them (if any) are in-network with your health insurance. The results may shock you. I'm looking at health insurance renewal options now, and NONE of the major carriers in San Francisco (Aetna, Anthem Blue Cross, Blue Shield, Cigna, UHC) have any in-network ambulance providers. Ridiculous!
  • Reserve calling 911 for when someone's life is in imminent danger. It's absolutely worth getting an ambulance if paramedics can help prevent a loved one from dying. When you really need it, it helps that paramedics can alert the ER about the patient's condition en route to help with a fast transition upon arrival.
  • Although you can request a specific ambulance provider if you call 911, the call center ultimately decides who to dispatch. The provider you end up with depends on the severity of the situation, where you are, and which ambulances are available.
  • You can request the paramedics take you to a specific hospital. Whether or not they agree may depend on the patient's condition and where you are. This may also impact how much you owe in either direction. I chose a different hospital than where the paramedics were going to take us because I wanted a dedicated pediatric ER.

More Insights On Surprise Ambulance Bills

Here are a few more insights I learned about surprise ambulance bills.

  • Of all the medical specialties, ambulances have the highest out-of-network billing rate. Dr. Karan Chhabra, who studies the issue, told the NYT that roughly 71% of ambulance rides are out-of-network and “have the potential to generate a surprise bill, with an average cost to the patient of $450.” My initial surprise ambulance bill was almost 8X that average and the total charges on the bill were 10X!
  • The number of volunteer-based ambulance providers is shrinking. Find out which providers are available in your area. Some volunteer-based providers will waive the cost of an ambulance ride if you have already made a donation to their organization that year for x-amount. Of course, you may not have any control over which provider is dispatched to your emergency. There are a lot of variables to consider.
  • In some areas, ambulance providers are unable to collect any money for their services if a patient is not taken to a hospital. This is one reason some volunteer-based providers are being forced to shut down.
  • Using your own car or a neighbor's car avoids an ambulance bill and may get you to the ER faster depending on the circumstances. But this isn't necessarily the best option depending on the severity of the emergency. If the person in distress doesn't need immediate medical assistance en route to the hospital, then it may be the better choice.
  • The amount you could owe for ambulance transport varies greatly by location, whether or not the provider is contracted with your insurance, and the local laws (if any).
  • If you get any type of surprise medical bill, do not assume you have a standard 120-day grace period to sort out the bill. Start making phone calls asap to try and get to the bottom of things. Resolving bills like these take a long time.
  • Keep track of every phone call you make and the names of the people you speak to and when. Never assume that the people you speak to will actually do what they claim they will do. Always follow up and confirm things with more than one representative.

Expect The Unexpected

Nobody ever expects to need an ambulance. I certainly didn't imagine I'd be calling 911 eight hours later when I woke up that crazy day. Although I had the determination and patience to get my surprise ambulance bill resolved in an acceptable way, I know a lot of other people may not. And that makes me upset. But I hope that positive changes will surface before too long.

In conclusion, this experience was a good reminder that we should expect the unexpected in life and do as much pre-mortem preparation and planning as we can. If you have dependents, make sure you understand the importance of life insurance and don't wait to buy a policy until it's too late.

Unexpected tragedies happen when we least expect them to. And as Sam recently experienced, we just never know when a friend or loved one could be gone.

And lastly, if we want something fixed, we sure have to fight for it sometimes. We will never surrender!

Thank you Sam for meeting us at the hospital that day and being on standby for six hours in the car because of COVID protocols! And thank you for also tolerating my frustrating rants throughout this long process.

Readers, what is the EMS system like in your area? Does your health insurance have any in-network ambulance providers where you live? If you are an EMT, what has your experience been like?

About The Author

31 thoughts on “A Broken Emergency Medical System (EMS) Means Lots Of Surprise Bills”

  1. Sam ! thank you for sharing your experience. While I understand the surprise of the bill can you please touch on the topic of Out of pocket maximum for a given year. The most you’ll ever spend out of pocket in a given calendar year is already set based on your insurance type, while obviously the end goal is to keep the $ out of pocket spend to minimum, the way I see this is like a subscription service to health care in USA.

    You pay the Maximum out of pocket per year (For you and your family). By 12 and you get a monthly rate. So doesn’t really bother me if Ambulance cost is X or some other weird mysterious hospital charge is Y as long as your insurance kicks in, Understanding the whole in-network and out of network ambulance topic you touched.

    Because at the end no matter how the price of one service (Ambulance) vs medication is it cannot exceed your out of pocket per year. Please share your thoughts. Thank you.

  2. My husband is a union firefighter/EMT for Philadelphia who had to make EMS rounds for thr first 10 years of his firefighter career. You wouldn’t believe the calls they have had to respond to, the reasons it takes forever to get an EMS to show in a timely manner is because people call 911 for fevers, toothaches, leg crams etc.
    People think they will get to the front of the line in the ER but that is only the case if you are literally dying otherwise you go wait in the ER like everyone else.
    Personally we know to just drive to the ER as fast as possible because we would get there before EMS would even arrive at our home.

  3. On the sell side of this, I know a guy that bought some vans and is in the ambulance business. They definitely get paid quite lucratively to drive patients around. 2 vans nets the business low 6 figures (after paying drivers, etc).

    I’d say not just the ambulance system is broken though, the entire healthcare system is broken in the states. A quick 15-minute consultation with a specialist runs $500+ after insurance. If during my annual check my primary doctor decides to add a Vitamin D to my blood test, on top of the regular lipid panel, that’s another $120.

    I feel like our healthcare system is one of the main reasons why I’d probably move out of the country in the future (and also to get a bit more out of my money via geoarbitrage).

  4. There’s talk on here sometimes, not always for sure, about not wanting to pay too many taxes. And I get it, to a point. But there’s a lot to be said for a well funded government that works for us. Regulations get written after legislation and are where the rubber hits the road for rulemaking. Having the right people in charge makes a big difference. Be weary of politicians of a certain stripe who parade about on anti-regulation platforms. When they say “anti-regulation” take them at their word. They want to make it easier for industry to deregulate which often (not always) leads to broken systems of exchange—in this case, many of your commenters are noting the broken medical system.

  5. Holy crap! That’s insane. Yet, another part of the healthcare system that’s screwed up.
    I never had to call an ambulance so I never knew about this. I missed the previous articles and just went back to read them. Lazy summer…
    I hope we never have to call an ambulance. We live one block away from the hospital. It’s probably easier to just go to the ER in our case.

    1. Yes, totally crazy. If you’re that close to the ER, just walk there or drive if you ever have an emergency. It will be faster and one big giant headache less to worry about.

  6. “Keep track of every phone call you make and the names of the people you speak to and when.”

    This is great advice. I keep a log for every claim, medical or otherwise, and it has always been useful.

    1. Yes! And I find asking for the person’s name/ID also makes them more resourceful/better behaved. It’s also very helpful on follow up calls to be able to say, “I spoke with — on –(day)– and she said –“. Helps keep people honest. I always ask them to update the notes on my file as well. If I hadn’t asked one of the AMS reps to input notes, I would have had a much harder time proving that they did in fact send my account into collections by mistake when my account was supposed to be on hold.

  7. Thanks for fighting the health insurance and ambulance company to get this situation resolved!

    I wonder how many people would just roll over and pay, or not pay at all actually.

    It’s really a situation about expectations. We knew calling the ambulance would cost a lot. But in my mind, I was thinking it would cost between $500-$1000, not over $4000.

    I do wonder what would happen to the frequency of ambulance calls if everybody knew they had a chance they’d have to pay thousands of dollars.

    Why does Price gouging have to occur during our most vulnerable moments? For some, It’s like, hand over your life savings or else you will not get the medicine to save your life. How is that good for humanity?

    What percentage of his problem would you a tribute to the health insurance company and the EMS company? It is kind of maddening that for us to pay $2300 a month for health insurance, we were still faced with a $3,000+ health insurance bill.

    It immediately makes me wonder what the hell is the point of paying so much for health insurance. So that’s really look into this for open enrollment for next year.

    1. I think the biggest problem here is with the government. Because there is no federal legislation or oversight, and most states don’t deem EMS as essential, patients and families are suffering.

      Vital EMS crews and ambulance providers can’t get enough government funding to retain employees and cover their costs. And insurance companies are just focused on profits and paying as little as they can get away with.

      Without federal mandates, insurance companies have no incentive to offer better out-of-network benefits for ambulances. And most consumers have no idea just how screwed they could be financially if they need an ambulance even with insurance. But so much also depends on where you are.

      For example, a friend of mine lives in NC (where EMS is deemed essential) and had to call an ambulance for her son. She only had to pay a couple hundred bucks with no insurance headache. Most Americans aren’t that lucky.

      I certainly didn’t think we would end up in the billing mess we did because we had insurance. Insurance is supposed to protect you from huge bills. But until EMS is deemed essential everywhere and the government puts in Federal legislation and oversight, insurance isn’t going to offer that much financial protection for most consumers.

      Even though the ambulance situation sucks in terms of insurance, I absolutely think having health insurance is a must. Without it, getting a child a standard set of vaccines could easily cost $700-800 a visit, a simple doctor’s checkup could wind up being $300-500, and an unexpected hospital stay could easily be in the tens of thousands, and so much more. Costs are out of control!

  8. You brought up a lot of good points. But as an owner of a Critical Care EMS (no-911 contract on purpose cause over 1/2 never pay their bill).

    I can assure you that some insurance companies are pure evil when it comes to paying claims and even when contracted some pay only $90 for a MICU transport. That does not even pay 1/3 of what that transport costs. Industry costs and salaries have gone through the roof, but their has been ZERO additional reimbursement from the government or private insurances. Until EMS is deemed as essential and compensated as such, these big 911 providers won’t go in network and must charge more to make up for the shortfalls from insurance.

    All of healthcare is very delicate at the moment. Thanks for sharing some light on it.

    1. Thanks for your insight Phil. Interesting on not contracting with 911. I never even thought about that side of things. If an insurance co is actually contracted and isn’t even honoring agreed contract rates, that’s so messed up. I totally agree EMS needs to be deemed essential!

      1. I am in healthcare as well. (not EMS). You would be shocked at the number of times insurance does not pay contracted rates.
        Why do you think they make billions in profit every year? They take your premiums and then short pay providers. There are so many small providers that won’t/can’t/not worth it to fight back.
        Reimbursement rates from both Fed programs and private insurance have been dramatically squeezed over the past decade. Really to the point that it affects patient care.

  9. Canadian Reader

    When I read the part about losing sleep and back pain flaring up, I thought I don’t know if its worth it. I’m happy to hear you had the tenacity to make insurance pay! It’s so aggravating to feel like you’ve been duped when you are forced to deal with these insurance booby traps. Kudos to you for winning this fight and trying to educate others.

    1. It’s one of those things where once you start the process, you don’t know how deep the rabbit hole goes. And you don’t want to give up halfway, otherwise, all your previous effort was for not.

      I am proud of my wife for getting things through until the very end. And I know her posts will help educate other families during times of medical emergency. And I hope these type of post help move the needle for positive legislation.

    2. Thanks! It definitely gave me physical and mental anguish, but I just couldn’t let it go. Maybe if it was me who needed the ambulance I would have caved in. But because it was our helpless little daughter who needed emergency care I just had to do everything in my effort to fight back on the charges.

  10. I absolutely, without a doubt, passionately and highly dislike the healthcare system in the United States. I told my friend to call 911 once in my life. It was after I played basketball and I went extra hard and sprained an ankle. Then afterward the game, I have trouble breathing all of a sudden and shortly after, I’m breathing frantically and can’t control my breathing. I yell at my friend to call 911, he seems hesitant but I couldn’t risk it and I yell even louder, almost screaming, to just call 911. He calls.

    They helped me breathe normally again and to calm down and transported me up the hill to inside the ambulance. They tried to get me to give them my social security number and phone number and I politely declined. They tried to get me to the hospital and I politely declined as well. I received zero bills in the mail.

    Reading your story horrifies me into thinking what would have happened if I consented to going to the hospital and getting treatment. I am absolutely terrified of receiving healthcare in the United States of any kind. I think a simple medicine prescription can cost hundreds of dollars in the really bad cases.

    Glad to hear that you successfully fought the system and that everyone was OK and healthy in the end. We have to fight for what’s right and not let others take advantage of us while taking care of our health at the same time.

      1. Thank you! I absolutely did get really lucky. They tried 2 more times and I just politely said no two more times. I was in good ol’ state of Texas.

        Also, thank YOU for highlighting your story! I think it’ll help me (and many readers) later down the road when I’m sure we’ll have to call 911 sometime in our lives.

  11. Each Ambulance company has a contract with your city or town. That’s how the game is played. They have rates for each contract differ. Some citys have their own ambulance service in bigger cities.

  12. I got hit by a car while riding my bike to work years ago. An ambulance responded to the scene, but I declined transportation to the hospital because my injuries were very minor. I only realized later on that my insurance plan would have covered the ambulance 100% if I was transported to the hospital, but since I declined, the ambulance company billed me a few hundred dollars, and my health plan refused to pay for it.

    At least it wasn’t as bad as my insurance refusing to pay for a secondary hearing test for my newborn after he failed a newborn hearing screening. I fought that one hard but still lost.

    1. Oh that’s interesting on the claim getting denied because you weren’t transported to a hospital. Perhaps it worked out for the better though because the charges you may have received from an ER visit may have been much higher than what you had to pay for the ambulance. Shocking on the denied claim on the secondary hearing test.

    1. You can do a quick google search to start using your city and EMS ambulance providers as search terms. That’s how I got the list of EMS providers in San Francisco. Then you can follow up with a call to your insurance company and ask them to check if any are in-network. They should also be able to do a wider search based on an X-mile radius.

  13. There are no in-network ambulances in my area either. Crazy! I had no idea that EMS is handled at a state level and that so many states don’t consider it essential. That is shocking. I’m glad I don’t live in a rural area because I’d probably be screwed.

    Dealing with insurance stuff is such a PITA. I spent several hours on the phone last year fighting a bill that my insurance processed incorrectly. It took talking to 4 or 5 different people until I finally got a straight answer and a revised claim. There’s such high turnover in customer service that most reps you speak with really don’t fully understand what they’re talking about. Frustrating.

    Thanks for raising awareness Sydney and glad you got your bill sorted out!

  14. Similar happened to me years ago. Obamacare says that emergency services should be paid at in-network, if I remember correctly. My wife had an emergency ectopic pregnancy 6 years ago. Went to an in-network hospital. The physicians was in-network. The radiologist and anesthesiologist were in-network (sometimes they are not, causing unexpected bills). However, one physician assistant was not in-network. He billed more than any other part of the bill. I was upset and even got quoted in a Consumer Reports article. In the end, my insurance caved and paid the full charge of the bill, which surprised me, since normally insurance companies are tough.

    I wrote an article years ago on 9 Tips to dealing with insurance companies, but can’t find it on the web right now. Thankfully, we are all in good health now, so no need for it of recent.

    1. Glad your insurance paid! What you went through should be avoidable now under the No Surprises Act. It just doesn’t cover out of network ground ambulances.

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