Role of States in Exclusion of Ground Ambulances from NSA

Exclusion of Ground Ambulances from No Surprises Act

The No Surprises Act (NSA) will prohibit most surprise bills, reducing out-of-pocket costs for emergency services and non-emergency services where the patient unintentionally sees an out-of-network provider. The recently enacted No Surprises Act (NSA) provides landmark protections against surprise billing in a wide range of settings but not for ground ambulances. You will be surprised to know that at least half of all ambulance rides may result in a surprise bill, with bills averaging $450. Congress has expressed interest in revisiting surprise billing for ground ambulances once it gathers more information. The NSA created a ground ambulance advisory committee of stakeholders and experts to develop recommendations related to disclosure of charges, surprise-billing protections, and enforcement mechanisms. You can refer to our blog on “Exclusion of Ground Ambulances from No Surprises Act” for the current legislative scenario and the role of local government. In this blog, we will discuss the reasons for the exclusion of ground ambulances and the role of various states in the exclusion of ground ambulances from NSA.

Reasons for Exclusion of Ground Ambulance

As per a survey report in 2020, 37 percent of emergency ground ambulance rides were provided through local fire departments, 25 percent through other government agencies, 30 percent through private companies, and 8 percent through hospitals. State and local regulations create barriers for publicly funded providers, such as local fire departments, to contract with insurance companies as in-network providers. Let’s consider an example of Houston, where the ambulance reimbursement rates are set by municipal ordinance, which means rates cannot be lowered during insurer contract negotiations. These rates may be set high to influence Medicare and Medicaid reimbursement, which is based on the average emergency medical service (EMS) rate per region. Interestingly some states, like Colorado and Delaware, have chosen to exempt public agencies from protections altogether, meaning that patients who use ambulance services run by a publicly funded provider may receive surprise bills. The complexity of working with local governments was cited as one reason ground ambulance coverage was excluded from the NSA.

Preventive Actions Taken by States

There are several states who have addressed out-of-network protections for ground ambulances. For state-regulated fully insured plans, 10 states provide some protection for consumers from surprise bills by out-of-network ground ambulance services; six provide guidance on reimbursement rates, though some use billed charges as a factor in that guidance, meaning providers can still charge insurers high rates even if the patient is only responsible for in-network cost-sharing. High rates, in turn, may contribute to higher premiums for consumers. 

Some states have released data showing the positive impact of reimbursement guidance. In Colorado, aggregate claims data showed that out-of-network ambulance providers charged $21,212,290 state-wide, but insurers ultimately paid out only about half that amount, $11,715,373, following reimbursement guidance that capped payments at either 350 percent of Medicare or an independently negotiated amount. In Florida, complaints related to ground ambulance billing have decreased since the passage of surprise billing protection in 2016, falling from 36 percent of complaints in 2015 to 5 percent of complaints in 2020.

Further Legislative Actions

Regulating authorities in Maine and Colorado have prohibited surprise billing by out-of-network ground ambulance providers. They noted that Medicare rates were a good benchmark for starting a discussion on reimbursement levels because ambulance groups are familiar with Medicare and accustomed to using Medicare rates to determine their payment structure. If regulators consider Medicare rates as a strong starting point for negotiations, collecting data on ground ambulance costs could help them push for the use of a smaller, more appropriate multiplier of those rates in determining reimbursement.

MedicalBillersandCoders (MBC) is a leading revenue cycle company providing complete medical billing services. We shared information on the exclusion of ground ambulances from NSA for reference only, for detailed understanding you can refer to our previous blog or blog from ‘The Commonwealth Fund’ for reference. In case of any assistance needed for ground ambulance billing, contact us at / 888-357-3226.