By Sandy West
KFF Health News
SAN FRANCISCO 鈥� Jagdish Whitten was on a run in July 2023 when a car hit him as he crossed a busy San Francisco street. Whitten, then 25, described doing 鈥渁 little flip鈥� over the vehicle and landing in the street before getting himself to the curb.
Concerned onlookers called an ambulance. But Whitten instead had friends pick him up and take him to a nearby hospital, the Helen Diller Medical Center, operated by the University of California-San Francisco.
鈥淚 knew that ambulances were expensive, and I didn鈥檛 think I was going to die,鈥� he said.
Whitten said doctors treated him for a mild concussion, a broken toe, and bruises.As he sat in a hospital bed, attached to an IV and wearing a neck brace, Whitten said, doctors told him that because he had suffered a traumatic injury, they had to send him by ambulance to the city鈥檚 only trauma center, Zuckerberg San Francisco General Hospital.
After a short ambulance ride, Whitten said, emergency room doctors checked him out, told him he had already received appropriate treatment, and released him.
Then the bill came.
The medical procedure
Traumatic injuries are those that threaten life or limb, and some facilities specialize in providing care for them. For someone hit by a car, that stabilizing vital signs, screening for internal injuries, and treating broken bones and concussions. Zuckerberg Hospital is a Level 1 trauma center, meaning it can provide any care needed for severely injured patients.
In emergency medicine, it is standard to transfer patients to centers best equipped to provide care. Ambulances are typically used for transfers because they are able to handle trauma patients, with tools to aid in resuscitation, immobilization, and life support.
At the first hospital, Whitten said, doctors performed a thorough workup, including a CT scan and X-rays, and advised him to follow up with his primary care physician and an orthopedic doctor. He was evaluated at the second hospital and released without additional treatment, he said.
The final bill
$12,872.99 for a 6-mile ambulance ride between hospitals: a $11,670.11 base rate, $737.16 for mileage, $314.45 for EKG monitoring, and $151.27 for 鈥渋nfection control.鈥�
The billing problem: Surprise bills are common with ground ambulances
Ground ambulance services are operated by a hodgepodge of private and public entities 鈥� with no uniform structure, or regulatory oversight, for billing 鈥� and most function outside insurance networks. Patients don鈥檛 typically have a choice of ambulance provider.
There are state and federal laws shielding patients from out-of-network ambulance bills, but none of those protections applied in Whitten鈥檚 case.
Whitten was insured under his father鈥檚 employer-sponsored health plan from Anthem Blue Cross. So when he received a nearly $13,000 bill months after his short transfer ride, he sent a photo of it to his dad.
Brian Whitten said the bills from the two hospitals 鈥� and the family鈥檚 out-of-pocket responsibility 鈥� were in line with what he had anticipated. But he was stunned by his son鈥檚 ambulance bill from AMR, one of the nation鈥檚 largest ambulance providers. Anthem Blue Cross denied the claim, saying the ambulance was out-of-network and required pre-authorization.
鈥淚t didn鈥檛 make a whole lot of sense to me, because the doctor is the one who put him in the ambulance,鈥� Brian Whitten said. 鈥淚t鈥檚 not like somehow he just decided, 鈥楬ey, can I take an ambulance ride?鈥欌��
Kristen Bole, a UCSF spokesperson, said in a statement that the health system鈥檚 standard of care is to stabilize patients and, when appropriate, transfer them to other medical facilities that are most appropriate to care for patients鈥� needs, adding that ambulance transfers between hospitals are standard practice.
While the medical system at large relies on negotiated prices for services, ambulance services operate largely outside of the competitive marketplace, said Patricia Kelmar, senior director of health care campaigns for PIRG, a nonpartisan consumer protection and good-government advocacy organization.
Ambulance transfers between hospitals to ensure the highest quality of care available are fairly common, Kelmar said. And with many hospitals being purchased and consolidated, it would follow that the number of ambulance transfers between facilities could increase as specialized medical units at any given hospital are downsized or eliminated, she said.
According to of private insurance claims data conducted in 2023, about 80% of ground ambulance rides resulted in out-of-network billing.
Generally, out-of-network providers may charge patients for the remainder of their bill after insurance pays. In some cases, patients can be on the hook even when they did not knowingly choose the out-of-network provider. These bills are known as 鈥渟urprise鈥� bills.
鈥淚t鈥檚 a financial burden, a significant financial burden,鈥� said Kelmar, who is a member of the federal lawmakers on surprise bills and emergency ambulance transportation.
Eighteen states have implemented laws regulating surprise ambulance billing. A California law cracking down on surprise ambulance billing took effect on Jan. 1, 2024 鈥� months after Jagdish Whitten鈥檚 ambulance ride.But Kelmar said those state laws don鈥檛 really help people with employer-sponsored insurance, because those plans are beyond state control 鈥� which is why federal legislation is so important, she said.
As of 2022, federal law protects patients from receiving some surprise bills, especially for emergency services. But while lawmakers included protections against air ambulance bills in the law, known as the , they .
The resolution
Whitten鈥檚 father filed an insurance appeal on his son鈥檚 behalf, which Anthem granted. The insurer paid AMR $9,966.60.
Michael Bowman, a spokesperson for Anthem, said AMR had not submitted all the information it required to process the claim, leading to the initial denial. After consulting with AMR, Anthem paid its coverage amount, Bowman said.
But the insurer鈥檚 payment still left Whitten with a $2,906.39 bill for his out-of-network ambulance ride. Brian Whitten said he called an AMR customer service number several times to contest the remaining charges but was unable to bypass its automated system and speak with a human.
鈥淚 couldn鈥檛 find a way to talk to somebody about this bill other than how to pay it, and I didn鈥檛 want to pay it,鈥� he said.
Unsuccessful and frustrated, Brian Whitten paid the remaining bill in January 2024, he said, concerned it would be turned over to a collection agency and hurt his son鈥檚 credit 鈥� and his well-being.
There was one more twist: He was shocked when he later reviewed his credit card statements and discovered that AMR had quietly but fully refunded his payment in October.
鈥淚t鈥檚 amazing that he got his money back,鈥� Kelmar said. 鈥淭hat鈥檚 what鈥檚 shocking.鈥�
In a statement, Suzie Robinson, vice president of revenue cycle management with AMR, said the company鈥檚 third-party billing agency regularly performs audits to ensure accuracy. An audit of Jagdish Whitten鈥檚 bill 鈥渞evealed that the care provided did not meet the criteria for critical care,鈥� Robinson said, which prompted the full refund.
Robinson said audits indicated fewer than 1% of its 4 million medical encounters annually are billed incorrectly.
The takeaway
Robinson said patients who feel that AMR has billed them incorrectly should contact the company via email.
For patients in need of an ambulance in an emergency, there are few protections 鈥� and usually few options: Sometimes you don鈥檛 have a better choice than to get in.
require that health plans cover certain surprise bills, with patients paying only what they would if they had received in-network care. Expanding those protections to ground ambulance bills would require Congress to act.
Ambulance providers deserve to be appropriately compensated for their vital role in our medical system, Kelmar said. But the system as it stands almost incentivizes providers to charge a higher rate, which can lead to surprise billing and financial hardship for patients and their families, she said.
Kelmar said she worries not just about the debt those bills create for consumers but also that people may decline vital ambulance transportation in an emergency, for fear of getting hit with an exorbitant bill.
鈥淲e just need to bring some sense back to the system,鈥� she said.
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