The No Surprises Act protects consumers from many unexpected charges, but not those for ground ambulances. Here’s what you need to know. By Donna Rosato, Consumer Reports
I knew I shouldn’t put off facing the stack of medical bills piling up on my dining room table any longer. They’d started to arrive even before I got home after five weeks in the hospital, a mountain amid mounds of other medical paperwork and get-well cards.
My saga started in mid-March, when I had a cough that wouldn’t go away and a mild fever spiked to 103° F. I went to the emergency room, where I suddenly became unable to breathe.
I was put on a ventilator for 10 days and spent a few weeks in an intensive care unit, where I slowly recovered from the flu and pneumonia. (Though my symptoms were similar to those of COVID-19 and this happened during the pandemic’s first wave last year, I never tested positive for the coronavirus.)
After a stint in a rehabilitation hospital and physical therapy at home, I felt much stronger and ready to tackle that pile of bills.
So one sunny afternoon last June, I sat on my deck and ripped open each long white business envelope. Some were second notices warning me to pay up.
But I was fortunate: I have good insurance through my employer. Even though the charges for my care were about $330,000, I owed only a little over $3,100 out of my own pocket.
Aetna, my insurer, covered all my expenses beyond copays and coinsurance after I met my $1,500 deductible. Except for one bill: $3,000 for an ambulance ride from my local hospital to a larger medical center that my doctors thought was better equipped to treat me. The letter from the ambulance provider, American Medical Response, said my insurer paid only $1,200 because AMR didn’t have a contract with Aetna to provide emergency services. The remaining $1,800 was my responsibility.
I was shocked. I was sedated before my ambulance ride, so I have no memory of the 47-mile trip. There’s no way I could have checked in advance to find out whether the ambulance provider took my insurance—not that I would have wanted to in that moment.
In retrospect, I shouldn’t have been surprised. As a reporter at Consumer Reports, I’ve covered surprise medical bills and talked to dozens of people with similar experiences. I knew that out-of-network bills are most common in emergencies where patients have little or no control over who provides their care.
The issue of surprise medical bills took on more urgency with the COVID-19 pandemic, and in December, Congress passed a major COVID-19 relief and spending package. It included the No Surprises Act, which bans surprise medical bills in emergencies as well as those from out-of-network providers who treat you at an in-network medical facility. The changes take effect in January 2022. The ban even extends to air ambulances, which often don’t participate in insurance plans and can result in medical bills reaching tens of thousands of dollars.
But the law had one glaring omission: It doesn’t apply to ground ambulances, even though they are one of the most common sources of out-of-network bills and can leave consumers on the hook for hundreds or thousands of dollars.
“Congress fell short,” says Karan Chhabra, MD, a surgical resident at Brigham and Women’s Hospital in Boston. Chhabra was lead author of research published last year that found that 79 percent of all ground ambulance rides could result in an out-of-network bill. The study was based on a large national health insurer’s claims data from 2013 to 2017. Another study, published in 2019, found that 86 percent of ambulance rides to hospital emergency departments resulted in an out-of-network bill for patients with private insurance, a far higher rate than from other physician specialists encountered in an ER visit, including ER doctors and anesthesiologists.
Why would lawmakers leave a loophole for ground ambulances? Because cracking down on them is complicated, says Chuck Bell, programs director at Consumer Reports, which has long advocated for consumer protections against surprise medical bills.
One main factor: The ownership of ambulance services is extremely fragmented. Almost half are run by local governments, often via police or fire departments and partly funded by taxpayers, according to a RAND Corporation analysis in a 2019 report (PDF) for the Centers for Medicare & Medicaid Services. The rest are for-profit or not-for-profit companies that towns, municipalities, and hospitals contract with for ambulance services.
Federal lawmakers are loath to pressure local governments to spend more on ambulances or to raise taxes to cover the revenue they’d lose if they couldn’t collect as much for those services, says Loren Adler, associate director of the USC-Brookings Schaeffer Initiative for Health Policy, who has studied surprise medical bills.
There’s another factor, too: Over the past decade, private equity investors have moved into the ambulance business, and today about 10 percent of ambulance providers are owned by private equity companies. These companies saw a profit opportunity, given that they could go after patients for charges that insurers were unwilling to cover, Adler says. The biggest player is KKR, which happens to own AMR, the ambulance company that sent me a surprise medical bill.
In a statement, AMR said that it tries to keep the patient out of the middle and actively works with private insurers to negotiate reasonable in-network rates but that private insurers frequently decline to enter into contracts.
