By Michelle Crouch
When Christy Owca’s 17-year-old son flipped his Jeep in a crash in 2019, she was grateful that an ambulance got him to the hospital quickly and that his injuries turned out to be minor. So when the first bill from Gaston County’s ambulance agency came, she didn’t think twice about paying the $61 fee.
But more bills kept coming. Then came statements from her health insurance company, each showing a different amount she owed just for the ambulance ride.
Confused, Owca began making calls — to Gaston Emergency Medical Services, to her health insurance company, to supervisors at both places. She said she spent hours making calls over several months trying to get the situation sorted out. Each time, a representative assured her the issue would be resolved.
The bills and notices kept coming.
Then, one day while she was at work, something mortifying happened: She was notified by her company’s human resources office that her wages were being garnished for an unpaid medical bill — that ambulance ride.
“It was a total shocker and extremely embarrassing,” said Owca, who got the garnishment removed after she sent a complaint to the N.C. Attorney General’s Office about the incident. “If you need an ambulance, if you have a car accident or another emergency, you shouldn’t have to worry that they’re going to take your wages if you call 911.”
Powerful collection tools
Because most EMS agencies in North Carolina are government entities or government-affiliated, they have access to two powerful debt collection tools:
- Wage or bank account garnishment: State law allows EMS agencies to take up to 10 percent of a person’s paycheck each month or to garnish an unlimited amount from a bank account in their name.
- State tax refund seizure: Through the state’s “debt setoff” program, EMS agencies can intercept your state tax refund or lottery winnings. In 2024 alone, Mecklenburg County’s EMS provider, MEDIC, collected $2.5 million through the program — more than any other public agency in the state. (More than 500 N.C. public agencies made these collections last year, here’s a list of how much was collected by each.)
For ambulance agencies facing budget gaps and rising costs, these tools offer a crucial source of revenue and a way to recoup unpaid bills when costs are rising. EMS leaders say they’re forced to go after patients because insurance companies deny or underpay emergency transport claims.
Patient advocates respond that the practices are out of step with efforts in North Carolina and across the country to reduce the aggressive collection of medical debt. In 2024, the state’s hospitals agreed to a medical debt relief plan that prohibits them from using liens, wage garnishment or tax refund seizure to collect medical debt.
“People should not be pushed to suffer financially because they needed help at a critical time,” said Rebecca Cerese, health policy advocate for the NC Justice Center. “These types of punitive policies keep people from calling an ambulance when they need one.”
Two steps to take your paycheck
Unlike other states, North Carolina does not require ambulance agencies to get a court order to garnish wages or seize funds from a bank account, said Christopher McLaughlin, a professor at the UNC Chapel Hill School of Government who has studied policies related to government debt collection.
Instead, he said, N.C. law requires just two pieces of paper: a letter to the debtor notifying them of the garnishment and a notice to the employer or bank directing them to seize the amount owed.
It’s the same process that counties and cities can use if you don’t pay your property taxes, he said.
“They don’t need to go to court. They don’t need to get approval from anybody,” McLaughlin said.
The debtor can stop the garnishment only if they can prove that the agency has the wrong person or they can prove they already paid, McLaughlin said.
It’s not clear how many EMS agencies across the state use wage or bank account garnishment or how much they collect, but McLaughlin said he thinks most do.
$21M seized from tax refunds and lottery winnings
As for debt setoff, 469 government entities — including counties, cities and utilities — used it to collect $21.4 million from people’s North Carolina tax refunds and lottery winnings in 2024, according to a clearinghouse that helps agencies use the program.
Representatives for Wake County EMS and MEDIC — which serve the state’s two largest counties — told The Charlotte Ledger/NC Health News they use the debt setoff program, but they do not pursue wage garnishment.
MEDIC considered using wage garnishment in 2019 to address a budget shortfall but dropped the plan after public outcry.
A tactic of last resort
Gaston County spokesman Adam Gaub said he could not comment on a specific patient’s bill, citing privacy laws, and he declined a request for an interview about the county’s ambulance billing policies.
In a written response to questions, Gaub said Gaston’s ambulance service, known as GEMS, uses a sliding fee scale and does not garnish wages or seize refunds from patients who cannot afford to pay.
He emphasized that the agency uses wage garnishment and debt setoff only “as an absolute last course of action” after working with individuals and offering payment plans.
The agency’s policy is to send three bills over 90 days before turning a bill over to collections, which triggers the wage garnishment process. The county also sends certified letters to the patient and their employer notifying them of the garnishment.
GEMS collected $31,757 in wage garnishments and $244,168 from the debt setoff program in 2024.
The agency is already operating in a deficit, Gaub said. In 2024-25, GEMS brought in $16.6 million and spent $23.1 million, with the difference made up by the county’s general fund revenues, which includes property taxes.
“Not collecting for services rendered from those who have the capacity to pay would place an additional burden on Gaston County taxpayers and/or would negatively affect our ability to provide our current level of service,” Gaub wrote.
What happened to my tax refund?
In Charlotte, Mae Cynthia Glover was caught off guard in 2020 when the state tax refund she was expecting never arrived. Instead, she said she received a letter saying MEDIC had seized it to cover an unpaid ambulance bill.
The letter said her refunds would continue to be garnished every year until her full balance was paid, Glover recalled.
“It wasn’t much, but it would have been better than nothing,” she said.
The unpaid bill dated back to 2019, when Glover finished a week of double shifts at her job as a catering company dishwasher and began feeling dizzy and nauseous. Her sister urged her to call 911. Moments later, in the back of the ambulance, Glover’s heart stopped. Paramedics revived her with a defibrillator, and doctors later implanted a pacemaker.
Glover doesn’t remember the exact amount of the ambulance bill — only that it was in the thousands and she couldn’t pay it.
She set up a monthly payment plan with MEDIC, but she said she fell behind after her health forced her to stop working. The unpaid bill was sent to collections, triggering the tax refund seizure.
“It’s frustrating because you ain’t got no choice when you call the ambulance,” she said. “It’s usually a life-or-death situation.”
She said she was relieved when she turned 65 last year and got on Medicare, so she doesn’t have to worry anymore about a big bill if she calls 911.
EMS: Insurers leave us no choice
Ambulance providers say they wish they didn’t have to use collection actions like debt setoff and wage garnishment, but they have little choice because of how insurance companies handle emergency transport bills.
Medicare and Medicaid reimbursement rates are so low they don’t even cover the cost to run an ambulance, said Regina Godette-Crawford, a lobbyist for the North Carolina Association of EMS Administrators. And private insurance companies routinely underpay or deny claims because they often treat ambulance transports as out-of-network.
That leaves the patient responsible for the balance, sometimes totaling in the thousands of dollars.
In addition to low reimbursement rates, ambulance services are also grappling with rising costs, workforce shortages and increasing numbers of calls.
John Peterson, executive director of MEDIC, said the agency makes every effort to work with patients, offering financial aid to low-income patients and interest-free payment plans. The agency also sends “multiple letters, multiple correspondences” before taking action, he said.
He said MEDIC uses the debt setoff program only when patients don’t respond to repeated billing attempts.
“If we don’t hear from anybody, then … we have to do what any good agency or business would do, and try to collect those dollars wherever we can,” he said. “We are a safety-net provider, but we’re also a business. We have to be good stewards of taxpayer and patient dollars.”
MEDIC gets an annual subsidy from Mecklenburg County’s general fund, which is supported by property and sales taxes. The subsidy is expected to remain flat for 2025-26 at $22.5 million. The new county budget also includes $7.6 million for one-time capital purchases like new ambulances and equipment.
Other states have protections
In North Carolina, legislation unanimously approved by the state house aims to ease some of the financial pressure on ambulance agencies. House Bill 489 would require health insurers to treat emergency ambulance transports as in-network and reimburse providers at local rates. The proposed legislation says patients should pay no more than $100 per ride.
Nineteen other states have approved similar “surprise ambulance bill” legislation. In some states, such as Massachusetts and California, those laws include provisions that ban EMS agencies from using aggressive collection actions like wage garnishment, said Mona Shah, senior director of policy and strategy at Community Catalyst, a national nonprofit that advocates for medical debt protections.
Other states take different approaches to shield patients from harsh collection practices, Shah said.
In Texas, for example, wage garnishment for medical debt is banned entirely. And in New Jersey, a 2024 law says wages can’t be garnished for medical debt if a person’s income is below 600 percent of the federal poverty level — currently $192,900 for a family of four. That law specifically names ambulance services as subject to its provisions.
“While there are broader policies around hospitals not being able to garnish wages, there can be loopholes for ambulance companies,” Shah said.
It’s particularly troubling for a government ambulance agency to be garnishing wages, she said, because it jeopardizes a person’s economic stability for an emergency they couldn’t control.
“You expect your government to be there to help in times of emergency,” she said.
She added that the real problem lies with insurers failing to cover emergency ambulance bills in the first place — shifting the financial burden to local governments and, ultimately, patients.
“We should really be going after insurance companies for denying coverage,” she said, “not patients who call 911 because they have a medical emergency.”
This article is part of a partnership between The Charlotte Ledger and North Carolina Health News to produce original health care reporting.
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