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.
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.
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?