The ambulance chases a patient into the collection

In retrospect, Peggy Dula said, she shouldn’t have called an ambulance. He was the least injured of the three siblings in the car when he was hit by a pickup truck last September. His daughter even came to the accident site and offered to pick him up.

Jim Martens, 62, and Cynthia Martens, 63, Peggy’s brother and sister, were more seriously injured and en route to the hospital in separate ambulances. Peggy, 55, was told it would be a good idea for her to check out, too. So he took a ride with a third ambulance crew.

When the wreck happened, the siblings were visiting the horses that Peggy’s daughter Peggy trains at a barn west of her home in St. Charles, Illinois, about 45 miles outside of Chicago. Peggy, who was driving on an unfamiliar country road, pulled into an intersection, mistaking it for a four-way stop. The truck rolled into an electrical box and hit the side of the car.

Cynthia, who was not wearing a seat belt in the back seat, spent five days in the hospital with a brain bleed, a cracked rib and a lung injury. Jim also had broken ribs, which he found out days later – only after returning home to Tampa, Florida.

Peggy was “a little dazed” but mostly unharmed as three ambulances descended on the crash site, alerted by 911. He was seen briefly in an emergency room and went home with only a bruised sternum, thankful he avoided major injury.

Then came the bill.

Patient: Peggy Dula, 55, who works at a fine jewelry store in Geneva, Illinois

Total Bill: $3,606 for ambulance services.

Service Provider: Pingree Grove and Countryside Fire Protection District, a fire district serving over 50 square miles near Elgin, Illinois.

Medical Services: An ambulance ride to the nearest hospital and brief medical evaluation.

Last hour: The three siblings were charged for the same service: “Advanced Life Support Emergency Level 1.” This is the code for transport by a ground ambulance in response to a 911 call, and may include simple medical services such as an evaluation. All three were charged mileage fees. Jim and Cynthia were billed for 15 miles; Peggy was billed for 14 miles. But because they rode in separate ambulances, each from a different nearby fire protection district, they were billed three different amounts:

  • Cynthia was billed $1,250 — $1,100 for life support and $10 per mile — by the Burlington Community Fire Protection District.
  • Jim was billed $1,415 – $1,265 for life support and $10 per mile – by the Hampshire Fire Protection District.
  • Peggy was billed $3,606 – $3,186 for life support and $30 per mile – by the Pingree Grove and Countryside Fire Protection Districts.

And while private, for-profit ambulance companies have become notorious for high bills, Peggy and her siblings are being billed by taxpayer-funded fire departments.

How can charges for the exact same service vary so widely?

One photo shows Cynthia Martens in her home.  He stands by the window and looks out.
Cynthia Martens suffered a brain bleed, a fractured rib and a collapsed lung after the car accident and was taken to the hospital by ambulance. Her sister, Peggy Dula, suffered minor injuries but an ambulance bill that nearly tripled.(Eric Herclerod/KHN)

“The simple answer is that these bills are all made up,” said Dr. Karan Chhabra, a surgical resident at Brigham and Women’s Hospital in Boston and a former research fellow at the University of Michigan.

In a 2020 paper published in the Journal of Health Affairs, Chhabra and his colleagues analyzed claims data from a major national insurer from 2013 to 2017, looking at surprising ambulance bills. They found that 71% of ambulance rides were out-of-network, meaning ambulance companies weren’t bound by a rate that was negotiated in advance with the insurer and could essentially charge whatever they wanted. Even local fire departments may refuse to join local insurance networks.

“It’s often the municipalities that send out some surprise bills and often go after them in a really aggressive way,” Chhabra said.

Kieron Stout, chief of the Pingree Grove and Countryside Fire Protection Districts, said their charges are in line with the federal Ground Emergency Medical Transportation Program, which allows some public emergency services to receive supplemental payments for transporting patients with Medicaid, state-federal health insurance. Programs for low-income people. Ambulance services fill out a cost report, and if their average cost per ride is higher than the rate set by Medicaid, they pay the difference.

The Hampshire Fire Protection District uses the same program to determine their bill rates, and the Burlington Community Fire Protection District recently started a cost report process as well.

But ambulance services can get their full supplemental amount even though they charge non-Medicaid patients less than that average, said Jim Parker of the University of Illinois’ Office of Medicaid Innovation. The program is relatively new, though, and some services mistakenly think they have to raise their charges for every patient to participate, Parker said.

So for Medicaid patients, the program will pay the difference between the ambulance company’s cost and the standard Medicaid payment.

But for patients with private insurance, like Peggy, the fire protection district bills patients directly for the balance not covered by their insurance, Stout said, a practice known as balance billing. He also said that only those who live outside the district receive balance-bills in the district. At the time of Peggy’s accident, all three siblings lived outside the tri-district. (Both Jim and Cynthia eventually received settlements from Peggy’s car insurance.)

Congress aimed to balance billing with the No Surprises Act, which went into effect on January 1. The law limits patient responsibility for most surprise bills, such as an out-of-network anesthesiologist who puts a patient to sleep for surgery. For a ride to an in-network hospital or an air ambulance, almost all of which are privately owned.

But ground ambulances were, controversially, exempt from the law – even though ground ambulance rides were far more common. About 98% of the 1,498,600 ambulance rides in Chhabra’s study were by ground ambulance.

Chhabra suspects that ground ambulances received special treatment because federal lawmakers felt the need to “tread lightly” around their relationship with local governments. Many ambulance services are run by municipalities and may need to bring in enough revenue to cover their costs.

“They have to do it to cover their own budget,” Chhabra said.

Resolution: Peggy said her insurer, BlueCross BlueShield of Illinois, found $1,892 to be a “reasonable and customary rate” for the services Peggy received. It applies $400.23 to Peggy’s deductible under the plan’s cost-sharing requirements and then pays $895.06 – 60%. Pingree Grove and Countryside then billed Peggy for the balance of their charges, $2,710.94.

Peggy challenged the balance with Paramedic Billing Services, the company that handles the district’s billing, citing her siblings’ much lower charges. “Needless to say, I’m speechless at the outrageously high bill I received,” Peggy wrote. “I’m willing to pay $354.94, which (with my insurance payment) equals what my sister is being charged for the exact same trip.”

Michael Tillman, vice president of paramedic billing services, said patients must dispute the charge directly with the ambulance service. Peggy said her subsequent calls to Pingree Grove and Countryside went unanswered.

To demonstrate her good faith in the absence of an answer, Peggy said she sent $20 to Paramedic Billing Services. She got a letter back with a coupon saying she needed to set up a payment plan for the full amount, so she sent another $20. In June, she received a letter from a collection agency saying she owed $2,670.94.

“They weren’t really working with me, were they?” she said.

Peggy Dula is seen sitting at the kitchen table by the window.  He is looking at the medical bills.
Peggy Dula’s ambulance fees were nearly three times what her siblings were billed for identical services.(Bram Sable-Smith/KHN)

In a statement, a spokesman for John Simley, Peggy’s insurer, said the insurer pays for ambulance services according to the terms of the member’s plan. “Some ambulance companies may charge a lot more than the benefits” a member plan provides, Simley said. “This sometimes forces members to pay the balance for ambulance services that are not covered by their benefit coverage.”

Takeaway: Getting into an ambulance involves financial risk. Your health may demand it. But your wallet may be damaged. So understand your options.

Obviously, if you are seriously injured in an accident, you have no way of finding out if the ambulance is in your network.

However, if you’re feeling better — with a slight bruise or injury from a car accident or falling off your bike — remember this: You don’t have to go in because an ambulance rolls up. They arrive because the police report their accident or a passerby calls 911.

Calling a friend or car service like Uber or Lyft to take you to the doctor, urgent care, or hospital emergency room can save you thousands of dollars. (And please take timely follow-up care for any possible head injuries.)

It’s also worth knowing if your local fire department’s ambulance service is in your insurance network, information that may influence your decision.

Of course, all of this raises the larger question of whether ambulance operations should be revenue generators at all.

“Or should it be something that’s good for the public that we pay for with our taxes like a fire department or a police department,” Chhabra said, “who I’ve never heard of getting a bill from?”

Bill of the Month by a crowdsourced investigation KHN And NPR which dissects and explains medical bills. Have an interesting medical bill you want to share with us? Tell us about it!

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