Ambulance Billing - No Surprises Act

We were on vacation when my daughter, who has a rare disorder, needed an ambulance. She has good coverage through the ACA Marketplace, but we were out-of-network. They took her into an ambulance to run tests and then took her to the hospital. After some fluids and rest, she was able to regain consciousness and was consequently released a few hours later. This is where our journey into the realm of out-of-network surprise billing began. Since my daughter had met her deductible for the year, we were expecting that her emergency ride would be mostly covered, short of a reasonable co-pay. Not so fast! As it turns out, emergency services are provided by local governments and private companies, most of which do not contract with insurance companies. This is the glitch: since they don’t contract with insurance companies, there’s no contracted discounted cost. Generally, when you receive an EOB (Explanation of Benefits), you’ll see the provider cost, the allowable rate, the insurance portion and your portion. That allowable rate is what the insurance company and provider agree to in terms of cost. Your portion is typically the difference between what the insurance company pays (based on their contracted amount), and what the provider charges. However, since the local governments and private companies don’t generally have contracts with insurance companies, there’s no “allowed/adjusted” cost. So what you pay is the difference from the charged cost and what the insurance company pays, and they never pay full price. All of this means that you pay more than you’d expect for a service that you’re not in a position to shop around for. After all, this is an emergency! In my daughter’s situation, the ambulance bill was $2,700 and the insurance company’s discount rate was $625 leaving a balance of $2,075. That’s a hefty surprise for a 15 minute ambulance ride. I actually know another person who had to be airlifted due to a rattlesnake bite and her bill is $25,000.This type of situation is categorized as ‘surprise billing’ and was a hot topic in Congress last year before the pandemic. Surprise billing occurs when a patient unknowingly receives care from an out-of-network provider or facility and is later hit with a large surprise bill. Congress took action with the No Surprises Act that goes into effect in 2022 but unfortunately, ground ambulances are exempt from the legislation. This is a nationwide issue but glaringly obvious in Washington, California, Florida, Colorado, Texas, Illinois and Wisconsin, where nearly two-thirds of ambulance rides resulted in out-of-network billing according to a Kaiser Family Research study. As part of the No Surprises Act, Congress is required to convene an advisory committee that will provide recommendations on ways to protect consumers from out-of-network surprise bills for ground ambulances. We can hope there will be some follow up to what seems like an oversight. Most likely, the local and state laws will have to be adjusted as well. In the meantime, what can you do? When you need an ambulance, you simply need an ambulance!You can start by understanding your state’s laws in this matter. Each state has their own set of laws and they vary widely. If you are hit with one of these typically large out-of-network surprise bills by a county government or provider, start with contacting your  insurance company. This Patient Advocate site has great tips on how to appeal to your insurance company. The insurer  may also be aware of your state's unique escalation processes. The next step is to try and negotiate with the provider. I honestly don’t hold out much hope for reduced costs but it’s worth a shot and if you don’t get a reduction, be sure to ask for a payment plan if you need one. These aren’t particularly effective but until laws are changed you can be aware, be educated, and make your opinion heard with your legislators.