bookmark_borderHere is a Surprising Solution to Startling Ambulance Bills

Medtelkasten Article #1

Surprise gifts are nice. Surprise bills are not. They’re unpleasant and no one likes them. Yet, surprise medical bills are an unfortunate reality for many in the US and will likely affect you too if you’re not careful. 

Surprise bills happen when a patient unwittingly gets treatment from a healthcare provider who isn’t part of their insurance network. Surprise bills also happen when you’re not at fault at all–an ambulance that’s not part of your network transports you to the hospital. Since they aren’t contracted with the system, your insurance pays little if any of that bill, shunting the rest to you. 

Now imagine someone in a life threatening situation. They’re incapacitated and someone else calls for help. The person getting the emergency care does not have the ability to shop around for the “best price” in-network ambulance ride. In these matters, time is the difference between survival or fatality. Patients can’t provide consent. Whatever ambulance is closest and can get to the person fastest–will get to save them critical time, but also get to bill them for ambulance fees. 

In the United States, over 20 million ambulance rides occur per year. Here’s why they matter. 

A Health Affairs report found that 71% of all ambulance rides risked surprise bills. On top of that, out-of-network charges were found to be a lot higher than in-network ones. Most of the rides are ground ambulances, while the rest are air ambulances.

What is an air ambulance?

Air ambulances were initially started to benefit patients in need and were run mainly by hospitals. Profit wasn’t part of the equation in some instances–some even operating at a loss on the service. Dr. Marty Makary, surgeon and professor of health policy and management at Johns Hopkins University in an interview with NPR describes it as such:

“Air ambulances really grew out of emergency rooms that decided, hey, we want to have a way to get people here faster. They were owned by hospitals. They were part of the hospital system. They were on the master hospital bill and often covered by insurance because it was a hospital service.”

This all changed after policy updates incentivized third parties to provide air ambulances. More money, more privately owned ambulances. 

The ironic part is that increased competition does nothing to drive down costs. Going from 2013 to 2017 accompanied 15% cost increases in air ambulance rides, even after inflation was factored in. This problem stems back to 2008, when the air ambulance industry was deregulated. Ambulances could take those with commercial insurance and charge them for trips.

The deregulation means air ambulance companies could raise their prices, insurance companies won’t cover and the remaining balance is shunted off to the unsuspecting patient. It’s all very punitive. 

A 2019 JAMA study found 86% of ground ambulance rides resulted in out-of-network bills. Ambulances are limited by geography. Sure, you can tell someone to go to a doctor miles away but you can’t really tell them to use an ambulance service from that far. 

Rural Healthcare

And speaking of distance, Air ambulance bills are also particularly troubling in rural areas. Those don’t have world-class care with high skilled physicians and healthcare workers within easy driving distance. Rural hospital closures only exacerbate the problem. As a result of write-offs on Medicare/Medicaid patients and uninsured patients–the insured have taken the hits.

Pew Research

Genesis of the Surprise Bill 

The insurance company only pays a small amount of what the total bill is, resulting in a crushing unsettled balance. This balance can range from hundreds of dollars to tens of thousands of dollars. Commercial insurance allows for balance billing in these cases.

The median out-of-network air ambulance bill was $21,698 more than the in-network price and over forty-eight times larger than the median ground ambulance surprise bill.

So what can you do about them?

Sally Pipes from Fierce Healthcare suggests transparency. She says that network information should be apparent to people before anyone is charged for services. The “in-network guarantee” must be clear. This could help lower surprise billing for non-emergency visits. 

Here’s a relevant example. 

You get a procedure done at a facility. That facility has physicians that aren’t in the same network as the insurance company that has a contract with it. On the day you go in, you happen to get a physician who is not in your network and they perform your procedure. As a result, the insurance company, who doesn’t have an agreement with this physician, will not cover the bill as in-network. It’s not fair. 

The proposal would make it so that in these non-emergency situations, the place you went to get your procedure done could NOT be marked by your insurance company as “in-network”–because not everyone employed there is “in-network.” 

Rideshare is Eating the World

While many expected rideshare services to falter in light of the COVID-19 pandemic, few have adopted well to the new consumer battleground. Uber pivoted into Uber Eats–allowing families to receive contactless delivery. In-person transactions fell but home delivery has picked up the slack. Companies like Just Eat Takeaway (JET) and Amazon have raked in obscene amounts of money during the pandemic.

The future pivot of these companies will lie in rideshare for healthcare. Rideshare makes accessible treatment feasible and reduces fear of surprise transport bills. No more juggling your schedule to get grandma to her appointment and back. For many older patients, rideshare could be an effective social engagement to get them to and fro their homes to their appointments. They wouldn’t need to worry about getting other family members to cover for them. I suspect that rideshare would drop the barrier for representative care by making it available for *any* individual with a little bit of training to be of service. 

It’s worth noting that generally the out-of-network trips are going down over time as more and more air ambulance companies join payer networks due to state-imposed regulations. Yet, until legislature with price controls are passed–I wouldn’t expect to see any marked decreases in these transport bills. 

As for doctor visits, not everyone can afford to take time off work or pay for babysitters to attend. On a wider scale, their preventative care is diminished. They’re set up for expensive consequences due to something that they have little control over. 

Case Study: Lyft and Access2Care

Back in 2018, Access2Care and Lyft (the rideshare service) worked together to manage AmeriHealth Caritas DC’s transport program. 

“Transportation is usually the first and last touchpoint for a consumer accessing care and has a big impact on how they engage with the healthcare system. When rides aren’t convenient or reliable, it often results in delayed care and a disjointed member experience.” –Shea Long, VP of Innovation at Centene.

The impact of Lyft’s entrance is clear:

  • 40% decrease in emergency room (ER) utilization
  • 15% decrease in low acuity non-emergent (LANE) ER utilization
  • 12% decrease in ambulance utilization
  • 45% increase in compliance rate for 42 Healthcare Effectiveness Data and Information Set (HEDIS) measures

Further pilot programs in Ohio, Florida, Georgia, Texas showed similar improvements.

With a rideshare program, there were fewer 1-star ratings, a 99% on-time arrive rate and a two-thirds decrease in member-rider complaints. In the past, non-emergency medical transportation rides had a 28-minute wait time on average. With Lyft, this came down to 7 minutes.

Statewide Success

Another program in Tennessee was so successful that it was scaled up for the entire state. With the program, there was a 44% increase in primary care physician visits and a stunning 90% decrease in “transportation-related grievances.”

An Uber study found a 7% decrease in ambulance rates after it entered a new location. Wait time for the remaining ambulances was likely reduced and thus, more deaths may have been prevented.

Lyft has demonstrated their ability to improve access to care through partnering with organizations to provide emergency rideshare ambulance services

Ridesharing allows patients to pick which hospital they go to–which may lead to better outcomes. For emergency situations, dispatchers would pick ambulance providers based on proximity and how severe their situation was rather than insurance network. This makes sense–most emergencies are time sensitive. If you started having health problems, you wouldn’t want to delay getting to the help you need.

Something also tells me that you if you need emergency services, you’re not exactly going to have the ability to research whether the ambulance en-route is compatible with your insurance plan. Even more of a kicker is that air ambulances, in most casesdon’t provide significantly better outcomes.


The Department of Transportation has to enact regulation to impress fair practices unto these private ambulance companies. While the Uber and Lyft initiatives are worthy of testing further rollouts, the root of surprise emergency will persist until legislation is passed setting price controls. Until then, we’ll just have to wait, see, and advocate.