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March 4, 2020

Solutions for Air Ambulance Surprise Billing in Holding Pattern

Author Affiliations
  • 1Consulting Editor, JAMA Health Forum and JAMA
JAMA Health Forum. 2020;1(3):e200281. doi:10.1001/jamahealthforum.2020.0281

As the issue of surprise medical bills gets increasing attention in the national conversation about health care costs, one high-profile component that state and federal policy makers are grappling with is the soaring cost of air ambulance bills. Critically ill patients who are transported by air ambulance typically have no control over the selection of the provider, often leaving them on the hook when they are billed thousands of dollars for the service.

Privately insured patients are at financial risk for so-called surprise balance bills—the difference between prices charged by clinicians, hospitals, and other providers of health services and the amount paid by insurers—when they are transported by air ambulance companies outside of their insurer’s network. Such balance bills are on top of co-payments or other types of cost sharing that patients typically pay under their insurance coverage.

In February, the Casper Star-Tribune reported that the largest insurer in Wyoming, Blue Cross Blue Shield, had agreed to an in-network contract with Air Methods, an air ambulance company and the largest such carrier in the US. That arrangement, however, came after the state government in Wyoming had sought relief for this problem by applying to the federal Centers for Medicare & Medicaid Services (CMS) for a Medicaid waiver to lower air ambulance costs for the state’s residents.

The proposed waiver would have expanded Wyoming Medicaid to all state residents for the specific purpose of air ambulance transportation, with the goals of eliminating surprise billing of patients, reducing the average cost of flights while ensuring a set level of access and quality, and increasing price transparency for patients and employer groups. CMS denied the waiver on January 3.

Federal congressional committees are working on legislation, such as 2 bills introduced in the House of Representatives in February (the Consumer Protections Against Surprise Medical Bills Act of 2020 and the Ban Surprise Billing Act), to address the issue of surprise medical bills, including billing for air transport services. In addition to Wyoming, other states are tackling the problem, including California and Florida. Florida has a bill making its way through the state legislature that would compel insurers to pay “reasonable reimbursement to air ambulance services.” In California, a new law took effect on January 1 that was intended to shield patients from hefty bills from out-of-network air ambulance companies.

However, as a Kaiser Health News story points out, the new law does not protect consumers with certain types of health plans. This includes companies that are self-funding, ie, paying their employees’ medical claims directly rather than buying state-regulated insurance. According to the Kaiser Family Foundation, about 61% of workers in the US with health insurance coverage through their employer are in a plan that is completely or partially self-funded. The federal government regulates self-funded plans, which are generally not subject to state health insurance laws. Efforts by states to solve the problem of surprise air ambulance bills are also hindered by the Airline Deregulation Act of 1978, which prohibits states from regulating air travel rates, routes, or services.

According to a March 2019 report from the US Government Accountability Office (GAO), its analysis of the most complete data identified for air ambulance transports of privately insured patients, 69% of about 20 700 transports were out of network in 2017. The median price charged by companies was about $36 400 for helicopter transport and $40 600 for plane transport in 2017, an increase of more than 60% from 2012 prices.

“Increases in the prices charged for air ambulance transports may exacerbate the financial risks related to balance billing for those with private insurance,” the GAO report noted.

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