Congress hasn't focused much on surprise medical billing by ground ambulances, even though researchers found that they bill more in total than air ambulances.
However, out-of-network bills for air ambulances were much more expensive for consumers that receive them, researchers from the University of Michigan found in a study published Wednesday in Health Affairs. The authors said this is the first study to document potential costs for patients when plans don't pay for out-of-network ambulance transports.
The sum of potential surprise bills for individuals covered by a large commercial insurer from 2013 to 2017 was $646 million for ground ambulance transports and $456 million for air transports.
But the air ambulance bills were much more expensive at a median of $21,698 more than in-network rates, compared with $450 for ground transports.
The median surprise bill for air ambulances rose much more quickly than ground transports at an average 15% increase a year for air ambulances, opposed to 2% annually for ground transports.
The authors also found that 52% of nonemergency ambulance transports happened out-of-network, compared with 79% for emergencies.
"While this percentage was less than that for emergency rides, it is reasonable to ask why any nonemergency ride should occur out of network," the researchers wrote.
The prevalence of potential surprise bills for emergency ground transport was the highest of transport types studied at 79%, followed by rotary-wing air transports at 73% and fixed-air transport at 70%.
The American Ambulance Association did not provide a statement on the study.
Air Methods, a leading provider of air ambulance services, has argued studies based on data ending in 2017 are out of date. The company has said its rate of transporting privately insured patients in-network has increased from 12% in 2017 to 40% in 2019.
The Save Our Air Medical Resources campaign argued that insurers sometimes refuse to negotiate with air ambulance providers.
"These insurers often refuse to cover the cost of this service or deny coverage after the fact, based on 'medical necessity,'" a spokesperson for the SOAR campaign said.
The study authors said there are anecdotal reports of air ambulance providers going in-network because of states' efforts to regulate air ambulance charges, though states have limited authority over the industry.
Air ambulance balance billing would be banned in a leading bicameral, bipartisan surprise billing bill written by Senate health committee Chair Lamar Alexander (R-Tenn.), Senate health ranking member Patty Murray (D-Wash.), House Energy & Commerce Chair Frank Pallone (D-N.J.) and House Energy & Commerce ranking member Greg Walden (R-Ore.). The White House has also called for any congressional surprise billing solution to address air ambulances and included a ban in legislative text the administration floated during COVID-19 relief negotiations.
"Despite the financial burden of ground and air ambulance transportation, both have largely evaded state and federal legislation. Federal proposals to limit surprise out-of-network billing should incorporate protections for patients who receive ground or air ambulance transportation," the study authors wrote.