The Ride to the ER Was In-Network. The Ride Itself Was Not.

When Congress passed the No Surprises Act in 2020, patient advocates celebrated the end of balance billing for emergency care. But buried in the statute was an omission that has since cost American households hundreds of millions of dollars: ground ambulance services were excluded from the law's protections entirely.

The result is a paradox that defies consumer logic. You can be carried by paramedics to an in-network emergency department, receive in-network physician care, be admitted to an in-network hospital — and still receive a separate, uncontrolled bill from the ambulance company, which may be a private, for-profit operator with no contract with your insurer at all.

Why Ambulances Operate Outside the Network System

Emergency medical services in the United States are a patchwork. Some ambulances are municipal and funded by taxes. Some are fire-department based. Many, particularly in suburban and rural areas, are private companies operating under county contracts but negotiating independently with insurers — or, frequently, not negotiating at all.

Because no federal rule forces these operators into network agreements, and because patients in an emergency cannot shop around, the market dynamics that the No Surprises Act was designed to correct simply do not apply. Research suggests ground ambulance rides generate surprise bills in a majority of cases nationwide.

Air Ambulances: The Six-Figure Outlier

Helicopter and fixed-wing medical transport occupy an even more extreme position. A single air ambulance flight routinely produces invoices of $50,000 to $100,000 or more, driven by high fixed operating costs and aggressive private-equity ownership in the industry. Because insurers routinely reimburse a fraction of the billed amount, the remaining balance — sometimes tens of thousands of dollars — has historically landed on the patient.

The No Surprises Act does cover air ambulance balance billing, and that provision has meaningfully reduced patient exposure. Ground transport, however, remains governed by a patchwork of state laws, most of which apply only to fully insured plans and leave self-funded employer coverage — which covers the majority of working Americans — untouched.

What Patients Can Actually Do

If an ambulance bill arrives that you believe is unfair or unaffordable:

• Request an itemized statement from the EMS provider, including the level of service billed and the run report details.
• Verify medical necessity coding. Medicare and insurers cover ambulance transport only when it was medically necessary; miscoded non-emergency transports are a common error.
• Ask about hardship or fee-schedule programs. Many municipal and private services will settle at the Medicare-allowable rate or offer income-based reductions.
• Check your state's protections. States including Colorado, Texas, and others have ground ambulance balance-billing protections or voluntary arbitration programs; determine whether they apply to your plan.
• Appeal through your insurer. If the transport was medically necessary and no in-network option was reasonably available, an appeal arguing network adequacy sometimes succeeds.

The Case for Closing the Gap

Federal legislation to extend surprise-billing protections to ground ambulances has been introduced repeatedly and remains pending. Until it passes, the emergency ride that saved your life can still become a second, slower emergency — one that arrives by mail.