Over 25% of commercially insured ground ambulance trips could come with a surprise bill: study

More than a quarter of all ground ambulance trips potentially resulted in a surprise bill due to out-of-network transportation services between 2014 and 2017, according to a new Health Affairs study.

The analysis of commercial claims data found that 28% of commercially insured emergency ground ambulance transports resulted in a potential surprise bill, as did 26% of nonemergency trips.

Transportation provided by private- and public-sector ambulances was equally likely to result in a potential surprise bill during the study period, though those incurred by private-sector companies were 52% higher for common emergency transport codes during 2017, the researchers found. Further, prices and cost-sharing generally, but not always, tended to be higher among organizations owned by private equity or publicly traded from 2016 to 2017.

"These findings highlight substantial patient liability and important differences in pricing and billing patterns between public- and private-sector ground ambulance organizations," the researchers wrote in the journal.

The researchers also noted that pricing “varied widely” during the study period—“perhaps unsurprising” given the high prevalence of out-of-network services and nonuniform regulation of ground ambulances across the country, they wrote.

Eighty-five percent of the sample’s emergency ground transports were delivered out of network, as were 57% of nonemergency trips. These claims were covered in full by the insurer in most cases, the researchers found, with the remainder representing 28% and 26% of trips with a potential surprise bill.

The team’s analysis combined commercial claims data for ground ambulance transport from the Health Care Cost Institute (which includes claims from Aetna, Humana and UnitedHealth Group) with ground ambulance provider ownership records from the Centers for Medicare and Medicaid Services. About two in five claims were missing network status, which the researchers categorized as out-of-network claims.

The dataset excluded claims for patients older than 65 and those that could not be matched or were missing other information. Of the final sample, about 85% were for emergency transports. Transportation providers owned by private equity or privately traded made up 9% of emergency transports and 23% of nonemergency transports. Public sector providers made up 59% of emergency transports and 9% of nonemergency transports.

The new results follow a Peterson-KFF Health System Tracker analysis from last summer that found even higher rates of out-of-network charges for private health insurance patients—50% for emergency ground ambulance rides and 39% for non-emergency rides.

2020’s No Surprises Act prohibits most surprise billing for patients who may be unaware that they are receiving out-of-network healthcare services. The bill went into effect at the beginning of 2022, although it’s taken the industry longer to hash out the process for settling payment disputes between providers and payers.

Ground ambulance providers, however, were initially excluded from the federal government’s intervention even as their costs rose hundreds of dollars in the years leading up to the legislation.

Instead, the bill instructed government agencies to begin investigating future policy recommendations related to these services, leading the Biden administration to establish the Ground Ambulance and Patient Billing (GAPB) Advisory Committee back in November. The group’s first meeting was slated for this month but has since been rescheduled with no concrete date yet announced.

To these policymakers, the authors of the latest study said the high prevalence of potential surprise bills they found among emergency and nonemergency trips “suggests that surprise billing protections may be necessary for both types of ground ambulance transports.”

The researchers warned against using in-network prices as a guide for ground ambulance arbitration “given that only 15% of emergency transports and 43% of nonemergency transports were in-network among the three large national carriers.”

Finally, wide price variation across geographic markets would make arbitration approaches focusing on average prices an effective penalty against regions that already made efforts to bring down prices, they warned. On the other hand, they noted that the variation also represents a chance to benefit public-sector ambulance revenues without adding to the federal deficit, “an outcome likely to be important to lawmakers.”