Short ambulance ride, big bill

By Michelle Crouch

The Charlotte Ledger

After Cathy Head of Charlotte fell and fractured her shoulder in 2023, she was pleased that her health insurance covered almost all of the expenses for her care: the emergency room visit, the physician’s charges and months of physical therapy. Then she got the ambulance bill.

For a 4.5-mile ride to Novant Health Matthews Medical Center, Head was charged $1,397. Of that, Head’s insurance paid just $130, she said. Another $60 came out of an employer-funded account that helps cover medical costs.

That left Head on the hook for more than $1,000 — a charge she didn’t expect.

The reason? MEDIC, Mecklenburg’s emergency medical services provider, wasn’t in network with her health insurance.

“It was shocking because I pay a lot for insurance, almost $800 a month,” Head said.

In North Carolina and across the country, most EMS agencies are out-of-network for private insurers, leaving patients like Head on the hook for steep ambulance bills — even if they have what they believe is “good” insurance coverage.

Nationally, about 60 percent of emergency ground ambulance rides are out of network, according to an analysis of 2018-22 claims by Fair Health, which describes itself as “an independent nonprofit that collects data for and manages the nation’s largest database of privately billed health insurance claims.”

It’s a gap in the emergency care system that leaves patients with no control over costs at a moment when they have no choice.

“When you call 911, you don’t get to say, ‘I want an ambulance in my network,’” said N.C. Rep. Donnie Loftis (R-Gastonia). “There are people who call 911 for transport, and then three or four months later get a $3,000 or $4,000 bill.”

Loftis said that’s why he sponsored House Bill 489, which would require insurers to cover ground ambulance rides as in network. It says patients should pay no more than $100 per ride.

The bill passed the N.C. House in May with unanimous support and is awaiting action from the state Senate.  

Ambulance companies tend to stay out of network with insurers because they don’t want to accept the lower rates the insurers offer. And insurers don’t prioritize negotiating with ambulance agencies because there are so many small, local and varied providers, and because patients can’t choose their ambulance in an emergency anyway.  

A gap in the federal No Surprises Act

A federal law, the No Surprises Act, is supposed to protect patients from unexpected out-of-network bills for emergency care. Under the law, which went into effect in 2022, patients are required to pay only what they would owe if the care had been in network.

But the law notably excluded ground ambulance rides.

As a result, ambulance rides are now a leading cause of surprise medical bills and a major driver of medical debt in the U.S., patient advocates say.

To fill the gap, 19 states have approved surprise ambulance bill protections, according to Public Interest Research Group (PIRG), a consumer advocacy nonprofit.

The proposed North Carolina law would require insurance companies to pay the locally approved rate for an ambulance trip. If no local rate exists, it calls for the insurer to pay a minimum of either four times the most recently published Medicare rate or the provider’s billed charge, whichever is less.

To protect patients, the bill limits what they can be charged: no more than $100 or 10 percent of what the insurer has to pay, whichever is less.

In Charlotte, MEDIC charges $1,194 for most emergency ambulance trips, plus $29 per mile, according to the billing page on its website. Wake County EMS charges between $769 and $1,113, depending on the level of care provided, plus $13.73 per mile. 

Critics: NC approach will drive up health care costs

Insurers and business groups say they agree with protecting patients from surprise bills but argue that North Carolina’s bill, as written, would drive up health insurance costs by guaranteeing high payments to ambulance providers.

David Smith, who chairs the legislative committee for the North Carolina chapter of the National Association of Benefits and Insurance Professionals, said requiring insurers to pay a minimum of the local rate or four times the Medicaid rate gives ambulance companies no incentive to negotiate.

“If the floor is 400 percent, then what’s the ceiling?” he said. “I’d rather us say 400 percent of the Medicare rate is the ceiling. That would establish a reasonable amount of reimbursement and could force everyone to the table.”

Because EMS agencies in North Carolina typically operate without competition, there will be no market pressure to keep prices in check, Smith said. 

Patricia Kelmar, senior director for health care campaigns at Public Interest Research Group, said no other state, to her knowledge, has set a floor as high as 400 percent of the Medicare rate. A similar law in Indiana sets 400 percent as a cap.  

She said efforts to protect patients from surprise bills need to be paired with cost containment.

“We do need to solve ambulance surprise billing, and this is a good first step,” she said. “But it’s also important to get the pricing right. If we allow overcharging, that means our insurance premiums will be going up. We need a system where we’re actually setting a price based on the real cost of these services.”

She said her organization favors legislation that either caps rates at a percentage of Medicare or follows a model like Connecticut’s, where a state office sets fair rates for ambulance services every year, and local EMS providers can appeal if they want to set higher rates.

Ambulance budgets under strain

Loftis said the minimum reimbursement rates in the legislation ensure that ambulance services are paid fairly and can stay in business.

Many EMS agencies operate on thin margins and are struggling to keep up with rising costs, including fuel, equipment and the competitive wages needed to attract and retain emergency medical technicians and paramedics, explained Regina Godette-Crawford, a lobbyist for the North Carolina Association of EMS Administrators.

At the same time, she said, insurers underpay and deny claims, forcing agencies to bill patients directly for the difference. As a result, agencies are often left with high percentages of unpaid bills.

And while costs rise, Medicare and Medicaid reimbursements have not kept pace, she said.

“When we pick up a Medicare or Medicaid patient, we don’t even get enough to pay to have two paramedics on the truck,” Godette-Crawford said. “That means we have to try to collect more from privately insured patients just to stay afloat.”

MEDIC budget woes

In Mecklenburg County, MEDIC is under mounting financial pressure, said John Peterson, the agency’s executive director. 

“Our ambulances have gotten significantly more expensive. Fuel is more expensive,” he said. “And our No. 1 cost is labor — it’s more expensive because we needed to pay our folks more, gladly and rightfully so.”

He shared the following statistics to illustrate the challenge:

• In 2024, the agency had about $27 million in unpaid invoices — nearly a third of its $90 million budget.
• About 60 percent of people the agency transports are on Medicaid or Medicare, with reimbursement rates so low that Peterson said they don’t even cover the cost of running the ambulance.
• Emergency call volume is increasing about 6 percent every year, driving the need for more ambulances and EMS staff.

To help close the budget gap, 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. However, the county budget includes an additional $7.6 million for one-time capital purchases like new ambulances and equipment.

Peterson said the proposed law “is essential to ensuring EMS providers are fairly reimbursed and that the people we are here to serve aren’t caught in the middle.” 

State law wouldn’t protect everyone

The NC legislation wouldn’t change how Medicare or Medicaid pay for ambulance rides — those rates are set by the federal government. 

It also wouldn’t apply to self-funded insurance plans, which are commonly used by large employers and fall under federal, not state, regulation.

However, in New York, a similar state law prompted more self-funded plans to cover ambulance rides as an in-network service, according to a study that examined the law’s effects. The study also found that the regulation contributed to a 13 percent increase in ambulance prices.

Patient advocates say a national law is needed because that’s the only way to protect everyone.

“It’s a monopoly”

For Head, the $1,000 bill from MEDIC seemed especially excessive because the ambulance crew said they couldn’t do anything about her severe pain on the way to the hospital. Yet she was still charged for a high level of care.

Adding to Head’s frustration, MEDIC’s charges didn’t match what her insurance company’s explanation-of-benefits statement said she should owe: $839, not $1,207.

In an email response to questions, a MEDIC spokeswoman said she couldn’t comment on individual cases. But she said that, generally speaking, the agency charges the same rate regardless of whether a patient receives more advanced life support services or basic care.

She stressed that MEDIC offers charity care and free payment plans and tries to work with patients to pay their bills. 

After almost nine months of phone calls and letters, Head said she managed to get her bill reduced to $779. But the experience left her questioning the system.

“The bottom line is, it’s a monopoly,” she said. “When you call 911, you don’t have a choice. There needs to be more competition and a system where ambulance rides are in-network with insurance companies.”

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