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USA Today and Washington Post Articles on PIRG Report on Ground Ambulance Balance Billing

20 Dec 2022 9:53 AM | Matt Zavadsky (Administrator)

With the announcement of the members of Advisory Committee on Ground Ambulance and Patient Billing (GAPB), PIRG released a report on ground ambulance balance billing.

Download the PIRG Report here: https://publicinterestnetwork.org/wp-content/uploads/2022/12/EMERGENCY-The-high-cost-of-ambulance-surprise-bills-USPIRG-Education-Fund-December-2022-Final.pdf

The report acknowledges Arnold Ventures for its support.

The author of the PIRG report is on the GAPB.

The report has spurred media stories in the Washington Post and USA Today, included below. 

No highlights in these, as all the content is important.


Surprise bills from ground ambulances is next up in the move toward reform

Ground ambulances were left out of surprise billing legislation. Experts will meet next month to consider how to wrangle them.

Analysis by Rachel Roubein with research by McKenzie Beard

December 13, 2022


The Biden administration is set to kick off the work of a key advisory committee designed to help stop patients from getting hit with pricey surprise medical bills from ground ambulances, The Health 202 has learned.

It took roughly two years for the new committee to get its start. But the panel’s meetings are now set to begin in the new year, with the first scheduled for Jan. 17-18. A critical report will be due 180 days later on how to prevent patients from owing hundreds of dollars for receiving out-of-network ambulance rides through no fault of their own.

That’s according to a Centers for Medicare and Medicaid Services webpage detailing information about the advisory committee’s membership and its initial meeting, neither of which have been officially announced. CMS cites a Dec. 16, 2022, notice in the federal register, which suggests the information may have been inadvertently published early on the agency’s website.

The upcoming launch of the advisory committee’s work is a step forward in fulfilling part of a law Congress passed in December 2020The legislation shielded patients from getting slapped with large bills when they unknowingly get care from an out-of-network provider, including for air ambulance flights. Yet, it didn’t apply to ground ambulances, instead mandating key federal departments appoint an advisory committee to recommend options for preventing such bills. 

  • “The ground ambulance loophole is a big gap that harms consumers,” said Madeline O’Brien, a research fellow at Georgetown University’s Center on Health Insurance Reforms. “We’ve been waiting almost two years for the committee to get off the ground and [are] very excited for the actions that they could be taking to protect consumers in this really critical space.”

About the commission

The details: The charter for the advisory committee was officially signed in November 2021, and the Biden administration began soliciting nominees to serve on the panel. 

Roughly a year later, the committee’s membership is coming into focus. According to the CMS webpage, Asbel Montes will serve as the committee chair. He’s a managing partner at Solutions Group, which does health consulting and tech work, and leads the American Ambulance Association’s payment reform task force, according to his work bio. He referred The Health 202 to CMS for comment.

  • Committee members from the federal government include Rogelyn McLean, of the Department of Health and Human Services; Ali Khawar, of the Labor Department; and Tom West, of the Department of Treasury. 
  • Other members consist of a cross-section of the health industry, state and local government representatives, advocates and others. This includes Loren Adler, of the USC-Brookings Schaeffer Initiative for Health Policy; Adam Beck, of the major insurer lobby; and Patricia Kelmar, of PIRG, a public interest group.

The view from CMS: In a statement, a spokesperson said the agency is looking forward to hearing the committee’s recommendations, which will help inform new policies aimed at “preventing balance billing, improving communication as it relates to insurance options for service, and by providing upfront and easy to understand disclosures of charges and fees for ground ambulance service.”

State of play

Ground ambulance billing is particularly complex. For instance, many emergency medical transport services are operated by municipal and county governments, and so they must adhere to state and local regulations. Meanwhile, some municipal services may not contract with private insurance companies, according to the Kaiser Family Foundation. 

“The reality is there’s so much unknown that there’s wisdom to convening a panel of experts,” said Adam Buckalew, the founder of alb solutions who helped negotiate the surprise billing law as a GOP aide on the Senate health committee.

The ground ambulance panel has been of particular interest to the House Education and Labor Committee.

Chairman Robert C. “Bobby” Scott (D-Va.) and ranking Republican Virginia Foxx (N.C.) sent a letter, first shared with The Health 202, Friday afternoon urging HHS to “prioritize and complete its establishment expeditiously.” (The CMS webpage appears to be updated with information about the ground ambulance committee before the lawmakers sent their letter, though an Education and Labor aide said HHS had been alerted last month that the letter was coming.)

Jamie Pafford-Gresham, the secretary of the American Ambulance Association, said patients should be protected from surprise bills, but a “balanced approach” to addressing the payment is needed. She contends getting it wrong could jeopardize access to emergency care, particularly in underserved areas.

Onward: The report is just another step toward potentially banning patients from receiving surprise bills from ground ambulances. Congress will likely need to legislate in this space to make good on upcoming policy recommendations. 


Half of ambulance rides yield surprise medical bills. What's being done to protect people?

Ken Alltucker


December 13, 2022


When people dial 911, perhaps the last thing they think about is how much the ambulance ride will cost. 

But a report released Tuesday by U.S. PIRG Education Trust shows ambulance companies routinely bill out-of-network charges. This happens when an insurance plan's network doesn't include the public or private ambulance company.

Even after an insurer pays a portion of charges, about half of consumers are billed more. These extra charges add up to about $129 million each year, according to U.S. PIRG.

Congress passed a law creating an arbitration process as of January 2022 to protect consumers from surprise bills during emergencies or when an out-of-network doctor provides care at an in-network hospital.

The federal law, called the No Surprises Act, also protects consumers from costly air ambulance bills — but it doesn't address more common ground ambulance transports. 

"This was the big gap in the No Surprises Act and it should be closed," said Patricia Kelmar, senior director of health care campaigns at U.S. PIRG Education Fund. "Three million insured people every year are going in an ambulance for an emergency, and half of those folks are exposed to a surprise bill."

What to know about surprise ambulance billing 

  • Ground ambulances were excluded from the No Surprises Act in part because of the complex regulatory nature and large number of stakeholders. Ambulance companies are usually regulated by states and local municipalities.
  • About 51% of emergency ambulance rides included out-of-network charges that potentially exposed patients to surprise bills, according to Kaiser Family Foundation.
  • The median cost for a surprise ambulance bill was $450, a 2020 study found, but rates vary by state and region. The median surprise bill in Massachusetts and Minnesota exceeded $1,000 while California had the most expensive average bills at more than $1,200. 
  • Fire departments or other local government entities provided nearly two-thirds of ambulance rides in 2020 while private ambulance companies handled 30% of rides, according to Kaiser Family Foundation

Do states protect consumers from ambulance bills?

Ten states have laws to limit ambulances from billing patients beyond what their insurance companies pay, but those restrictions apply only to state-regulated health insurance plans and protections vary. For example: Maryland's protections apply only to publicly-owned ambulances and Colorado's prohibits private ambulances from such balance billing, according to the report.

The states with protections:

  • Colorado
  • Delaware
  • Florida
  • Illinois
  • Maine
  • Maryland
  • New York
  • Ohio
  • Vermont
  • West Virginia

A major loophole: State bans don't apply to most employer-provided health insurance plans, which are regulated under a Department of Labor law called the Employee Retirement Income Security Act.

"That's why we really do need a federal law to make sure that all insured patients have protection from surprise bills," Kelmar said. 

How is the federal government addressing ambulance billing?

A federal advisory committee created by the No Surprises Act is set to meet in January for the first time. It then has 180 days to make detailed recommendations on fee disclosures and strategies to protect consumers from surprise buildings.

U.S. PIRG recommends Congress amend the No Surprises Act to protect consumers from surprise ambulance bills. The federal law has prevented as many 9 million surprise medical bills through September, according to an analysis by Blue Cross Blue Shield Association and America’s Health Insurance Plans, a health insurance industry group. 

Why consumers need protection

Because people have no chance to compare prices or seek a better deal during an emergency, consumer advocates say it's unfair to stick patients with surprise bills. 

"When you call 911, you don't know what ambulance is going to come," said Eileen Appelbaum, Co-Director of the Center for Economic and Policy Research, a progressive think tank. 

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