A health care provider’s total charge for a good or service. A medical bill may include a fee for each service delivered (fee-for-service), a payment for each day in the hospital or other health care facility (per diem), a payment for each episode of care during a hospitalization (diagnosis-related groups, or DRGs) and/or a charge for every patient considered to be under the provider’s care (capitation).
In some cases, patients are charged more than is covered by their insurance, leading to “balance billing.” The most common source of surprise bills comes from ambulance services. The federal No Surprises Act of 2022 protects Medicare patients from out-of-network charges for emergency ambulance rides, but private insurers have no such protections in place. Ambulance services are often unwilling to agree to join plan networks, so they may charge insured patients rates higher than what’s covered by their insurers. In turn, the insurance company pays the ambulance service and then sends the patient the difference, which can be a hefty sum.
While some ambulance companies use balance billing as a way to make money, others do so out of necessity. Many ambulance services, particularly those in rural areas, have limited resources and must take patients to the nearest appropriate medical facility as quickly as possible. This means that they can’t afford to spend time negotiating with insurance plans and, in some cases, may even have to turn away some patients.
The cost of an emergency ambulance ride can vary widely from state to state, with most services relying on government-set reimbursement rates for Medicare and Medicaid patients. But the 14,000 or so ambulance services in the country that aren’t operated by a government, volunteer fire department or hospital tend to have no such rules. The result: Consumers can receive bills for thousands of dollars, or even more, for a single ride.
One of the most troubling examples of this problem came to light when a California couple received a $16,400 bill from American Medical Response for a five-mile ride to get their daughter to a hospital for treatment after she was involved in an accident. The couple says they didn’t qualify for the company’s financial assistance program and have spent months trying to work with AMR, their insurer and the hospital to resolve the matter. They say they’re worried that people will start to avoid taking an ambulance when they need one because of the risk of financial debt.
A spokesperson for AMR says the company has not been contacted by a journalist, but he points out that “we are currently assisting this individual with the appropriate paperwork in order to process their claim.” He also notes that “it is important to note that we do not attempt to collect on balance billing after an insurance company has paid on a claim.” It’s unclear what’s next for this couple or how their case will play out in court. For now, they’re left with a balance bill they say is unfair and should never have been charged in the first place. American Medical Response Billing