Ambulance service and self-pay patients

I’m generally of the opinion that most health care can be shopped for if a person is willing to put in a little time to use the available tools. As I try to bring to my readers’ attention on a regular basis, with a little planning and a little understanding of what is out there, it’s often possible to save thousands or even tens of thousands of dollars on needed medical services. For example, a while back I featured a story about a man who went to Thailand for shoulder surgery, saving more than $120,000 in the process!

But in some cases it just isn’t feasible to shop for a provider. Ambulance services come immediately to mind. I recently had forwarded to me by a friend a story about how the cost of ambulance services can get out of hand. Below are a few excerpts.

The Wild West of Ambulance Charges

Let’s say you get into an accident and an ambulance arrives to take you to the hospital. It could be for a life threatening injury, or more of a precaution. A few weeks later, a bill arrives for ambulance services. How much should you expect to pay?

The correct answer is that you never really know. Charges for ambulance transportation vary dramatically across the U.S. and from provider to provider. In Monterey County, California, the average minimum charge for basic life support (BLS) ambulance transportation is $2,206. A few hours away in Mendocino County, the average is just $575… health insurance may only cover a fraction of the charge if the provider is out-of-network. In an emergency situation, patients are unlikely to compare ambulance prices or find an in-network provider, which leaves many suffering from sticker shock. 

That’s exactly what happened to Robin Spring of Corralitos, California. Spring called 911 after becoming short of breath and was taken to the hospital in an ambulance. She later received a bill for $2,288. Citing the fact that the ambulance was out-of-network, her insurance covered just $750, leaving Spring with a balance of $1,538. But there were no in-network ambulance companies in Santa Cruz county, where Spring lived…

The article goes on to explain a root cause of the wild variation: Medicare.

A major factor behind high charges is that insurance reimbursements often do not reflect provider costs, leaving a small margin for ambulance companies. In 2010, the average Medicare payment was just 2% more than the average provider cost per transport. For many providers, the payment was less than the average cost per transport, meaning that the provider actually lost money transporting Medicare patients to the hospital. Insurance reimbursements, which are often based on Medicare fee schedules, may be even less…

Since margins are thin for Medicare and in-network patients, ambulance providers often avoid negotiating contracts with insurance companies or charge out-of-network individuals significantly higher rates in order to compensate…

While the uninsured and those with high-deductible insurance are usually the type of self-pay patients hit with high charges, in the case of ambulance services they can also hit people with more conventional health insurance.

Patients who have insurance and means, but use an out-of-network provider, face the highest out-of-pocket costs. When the ambulance arrives, they have unknowingly entered into an arrangement in which their insurance will likely cover only a fraction of the charge, if any of the bill, leaving them on the hook for the balance…

Other patients may lack insurance coverage and be unable to pay their bill. “50 percent of the calls we go on we don’t get any reimbursement for,” says chief paramedic Josh Nultemeier of King American Ambulance in San Francisco. One estimate put the collection rate (the percentage of ambulance charges that are actually paid) in San Diego county at just 33%…

When people need an ambulance, they’re usually not thinking about in-network benefits. In emergencies, the decision may be out of the patient’s control if a bystander calls 911 or if he or she is unconscious. And even when a patient is cost-conscious, there may be only one local provider or the decision may be made by the dispatch system. As the costs of America’s patchwork system vary dramatically, whether a patient receives a manageable bill or a crippling one is ultimately a matter of chance.

So, are there things self-pay patients (which includes a lot of people with conventional health insurance too, in this case) can do to protect themselves from high ambulance charges? Here are a couple of suggestions:

  1. If at all possible, find alternate transportation. Some injuries or conditions require a first responder immediately, and whatever the closest ambulance is to the patient is the right one, regardless of charge. But in other instances, just having someone drive you to the emergency room is the better option (and here’s how to save money on care in the emergency room).
  2. If you have insurance, know ahead of time which ambulance services are in your network, and if possible try to get the ambulance dispatcher to send an ambulance from that service. Again, in some cases the nearest ambulance is the right one, but in other cases a few minutes delay isn’t going to result in loss of life, limb, or bodily function.
  3. If you don’t have conventional health insurance, know ahead of time what your options are and what they charge. This will probably be harder in rural areas where choices tend to be fewer, but if you have choices find out which one will be best for you and your wallet before you need an ambulance.
  4. If you wind up in an ambulance not of your choosing (and that’s probably going to be pretty typical), you might be able to negotiate the bill down after the service is provided, just like other medical services.

One thing people should also remember is that ambulances are expensive to operate, and are typically on-call 24-hours a day. I read a recent blog post elsewhere complaining about an $800 charge for 5 mile ambulance ride.

Consumer Rage: The $798 Ambulance Ride

Jim Mathes took one bad step out of his apartment in early September and wrenched his back. The pain was so intense he had to crawl back inside on all fours. He needed medical care, but there was no chance he could get himself down three flights of stairs to his car. So he did what anyone would do; he called for an ambulance.

That turned out to be an even bigger misstep, sending him into the demanding arms of a multibillion dollar global industry, and leaving him with a nearly $800 bill for a 5-mile ride.

The ambulance crew helped him downstairs, but once there, he felt well enough to drive himself to Parkwest Medical Center hospital, only five miles away in Knoxville, Tenn. The technicians urged him to ride in the ambulance, however.

“It’s no big deal,” Mathes recalls one technician saying, repeatedly. So Mathes got in.

Maybe the ride wasn’t a big deal, but it was an $800 deal…

Two weeks after the back incident, Mathes was stunned by another pain — a $798 bill he received from Rural/Metro of Tennessee. By Mathes’ math, the cost was more than $150 per mile.

“If I’d have known it would cost that much, I would have crawled to the hospital,” he said.  His insurance won’t cover the ride, so Mathes is stuck paying the bill.

As if to add insult to back injury, the ambulance ride costs are itemized on a copy of the bill Mathes provided.  It says the per mile cost was really only $8.73. The flat rate for sending the rig anywhere was $755.

“I feel like I was duped,” Mathes said. “I’m glad we’re not paying the amount for gas per mile that they do.  Oh wait, that’s what they are asking me to do.  Unbelievable.”

This story was pretty interesting, mostly for the obvious missteps by the patient and misunderstanding of what ambulance service is for. Two quick points:

  1. Severe back pain is probably something that deserves a call to a friend or family member to have them take them to the hospital, or better yet perhaps an urgent care center or doctor.
  2. Ambulances are expensive to operate.

I’d actually found a version of this story posted on another site, and the comments there from several people were fairly instructive:

Dave: People forget you’re also paying for this service to be available 24/7. You have to pay the staff for being on call, the lights, the room, etc. It’s always there for you. If you need it at 2 in the morning on a holiday it will be there for you. People need to think about these things before complaining about using a service like this and then seeing a large bill.

Chris: I am a paramedic in a very large and busy 911 system. The gentleman complaining about his bill should have thought twice before calling 911 for back pain. In my professional opinion, back pain is not a true medical emergency requiring immediate transport to the hospital via ambulance. Because he chose to call 911, he now has to pay for the services he used. Ambulances carry a load of expensive drugs and equipment and are staffed by highly trained EMTs and Paramedics who need to be paid. As another poster commented, it is expensive to run a 24/7/365 operation. A new ambulance (without any equipment…just the vehicle) costs over $100,000. A heart monitor is about $10,000 and the stretcher around $4,000. Many publicly run EMS systems that get taxpayer funds receive FAR less than police or fire depts. To make up for that lack of funding, EMS has to bill. Next time save the ambulance for true life threatening emergencies and take a cab.

Jason: What people don’t seem to get is that ambulances haven’t been just “throw the patient in the back and take off” type transports since about 1960. You are getting a mobile hospital room with all the tools/equipment and skills needed to keep you alive. That costs money. Just one piece – the LifePak heart monitor/defibrillator – is close to $12,000 to purchase new from the manufacturer. If you don’t need all the fancy gear that an ambulance has, you probably don’t need to be taking an ambulance to the hospital. A back injury.. I’d want to transport that guy in case of spinal injury.

Rick: Actually, a new ambulance unstocked costs at least $180,000. A new Lifepak 15 (don’t make 12s anymore) costs $33,000. How do I know? I am a director at an EMS service and just bought 3 of each this year. ALS ambulance care costs a lot money because the equipment and personnel are not cheap.

I’m certainly no stranger to the idea that the charges for medical services can be wildly inflated and abusive to those without insurance or who are out-of-network (I probably wouldn’t have anything to write about on this blog if it weren’t the case). But medical services do cost money, emergency services tend to be the most expensive form of treatment because they’re expected to be available 24 hours a day/7 days a week, and assuming the ambulance ride was necessary, it’s probably worth remembering that the ambulance service has likely saved your life, limb, or other major bodily function.

Remember, the point of being a self-pay patient isn’t to just save money, it’s to get the best value for your money. In that light, an $800 ambulance bill to transport a heart attack victim to the hospital is probably a pretty good value.

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10 Responses to Ambulance service and self-pay patients

  1. Sammy Finkelman says:

    It looks like you shouldn’t call a regular ambulance, unless you know it is covered by insurance. Call Hatzolah. They come sooner and they don’t charge. They just ask later for a donation.

    • says:

      I wouldn’t go quite that far – if it’s going to save your life, I’d call the ambulance. But thanks for the tip on Hatzolah, looks like they’re only an option in urban areas with large Jewish populations, but they look like a great service! I found this online about Hatzolah being called in New York after the city’s 911 service couldn’t get an ambulance dispatched despite multiple calls: Williamsburg Hatzolah comes to aid when 911 system failed

  2. Meli says:

    I have a rare condition that my entire body goes into one huge muscle contraction. I was in my.PCPs office and had an attack. Before I knew it Phx fire and ALS showed up. My PCP requested them called and to have me transported. Phx fire was great started IV and tried to stop the.episode ALS arrived and said we carry the drugs you need. The trip was across a parking lot….$ 1,000 & charges for services I never received. My body was like a stone fell in between stretcher and floor n EMT service in Phx PATHETIC AND $1000 like prior poster I would rather had my bones break due to my condition …

  3. John says:

    No one is opposed to paying for any service but when the charges are excessive it becomes an issue. Lets be realistic medical charges are so high you could be forced to spend years working to buy new cars for doctors.

    The ambulance cost is beyond reasonable. I have researched one company that is operating in many states. At this moment who have a hatred do intense for them, they would love to see them disappear. My recent ride in an ambulance was a 10 mile trip to local hospital after having a seizure. I was not fully conscious when they came so I didn’t call them or authorize any service. Had I been more alert I would have denied the service knowing nothing could be done to aid my condition. I received an inflated bill because they are out of network with my insurance company.
    In the article it states the cost of an ambulance and equipment is about $100,000 but I’m one of thousands who will be paying for all cost. I feel my short ride with no care needed or equipment used with a price tag of $1769.17 is excessive.

    • says:

      There are a lot of inflated charges in health care for self-pay (and that often includes out-of-network) patients, and I’m not at all surprised that ambulances may be among them. Can’t say I know whether $1769 is a reasonable charge for an ambulance ride, but that $100,000 figure is for the ambulance alone, not the equipment. And of course there’s the personnel as well.

      My suggestion would be to find out what an in-network ambulance ride would have cost, and call the ambulance company and ask if they’ll settle for something a little more than that.

  4. Doug says:

    the ambulance fees are not justified when details are examined. All fleet -based businesses have about the same operating expenses. I operate a fairly large fleet of big rigs. Each rig is costs about $180K. I am told an medium duty ambulace is about the same. Our average driver makes more money than the average paramedic in our area, I know my maintenance expenses are higher because the rig’s parts, tires, etc. cost more and are done more often. if the ambulance is diesel we pay the same for fuel. However my trucks average < 7 mpg. the ambulances should get much better fuel mileage because they are lighter and not geared to move heavy loads. If the ambulance runs on gas they pay less for fuel per gallon. I suspect the ambulance has a malpractice coverage that we do not but I would guess my limits are considerably higher and we are required to carry policies that the ambulance does not. I would also venture that our group health benefits are better and cost more than the typical ambulance service offers their employees.
    To skip to the chase, our total cost per mile (everything in) is $2.00/mile (2015). this is a small fraction of what ambulances charge per mile. In spite of all the reasons/excuses I've heard, the only logical explanation for their inflated charges is to overcome their expenses from calls where they do not get paid. Any way you slice it, that's not an ethical business practice. We should not expect ambulance service to be free but the services need to keep their fees in line with what their actual operating expenses are + a reasonable profit.

    • says:

      Thanks for your comments. Two things to keep in mind, ambulances also have medical supplies, and unlike a commercial cargo (or similar) vehicle, they don’t routinely operate 40+ hours a week. Depending on the service and locale, an ambulance might only be on the road a couple of times each day, but the vehicle lease/payment still has to be made whether the ambulance goes out 3 times or 5 times or 10 times each day. Also, ambulances typically have crews of 2, whereas I’m guessing your rigs have single drivers. Double your employee costs for your rigs and I’m guessing your overall costs jump a fair amount, no? Oh, one more thing, I’m guessing your rigs try to have freight/cargo both ways, or you structure routes so as to maximize efficiency. Ambulances often return home empty, or if based at/near the hospital, their ride to the patient is empty.

      My point isn’t that there isn’t overcharging in the ambulance industry, it’s pretty typical in all of health care. But a lot of the complaints I’ve seen and responded to were of the “it would be cheaper to take a taxi!” or “how can it possibly cost $800 for a 10 mile ambulance ride!” Well, it’s pretty easy when you account for staffing, cost of the vehicle, and the frequency of use.

      • Doug says:

        Sean – Like an ambulance, many commercial vehicles have expensive specialized tools/equipment in addition to the vehicle. The cost of those vary depending upon what segment of transportation the vehicle is being used in. While most commercial trucks do operate 40+ hours a week, most transportation companies continuously have a percentage of their fleet that is unstaffed and struggle with turnover in the 80% range or more so personnel expenses for trucking is some of the highest in any industry. Yet as you point out, the vehicle payment or lease still has to be paid. Many trucking operations operate “team” drivers so in those companies there are two drivers in the vehicle that have to be compensated. You are correct that trucking companies try to operate efficiently and keeping freight on the trucks is a good way of doing that. But often that’s not an option so trucks operate millions of miles each year without compensation.
        I’d also point out that common ambulance billing practices seems to be to invoice for fees /services plus a separate fee for mileage. To compare apples to apples you’d have to divide a total ambulance invoice by the miles of the ambulance trip. This would raise the cost per mile even more. In trucking ALL expenses are considered in the per mile calculation .
        Operating any kind of fleet has it’s challenges but there is simply no way that the per mile cost of an ambulance is significantly more than that of a big rig truck.

  5. Rosalie says:

    It’s ridiculous I was given a 5 mile ride for 2000 dollars nothing was given to me that is out crazie why should we pay for someone else

    • Sean Parnell says:

      That does sound like a lot, but you got more than a “5 mile ride” – it was a ride in a on-call, professionally-staffed, mobile emergency room. That’s going to be pricey under any circumstances. Can you provide more details?

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