The Ground Ambulance & Patient Billing (GAPB) Advisory Committee released a comprehensive report to Congress this week, addressing the urgent issue of out-of-network ground ambulance balance billing. The report, dated March 29, 2024, delivers a set of recommendations aimed at reforming how patients are billed for emergency ground ambulance services, especially in situations where the ambulance provider is out of network. It builds upon the framework of the No Surprises Act but emphasizes the need for specific legislative action tailored to ground ambulance services.
In summary, the committee’s recommendations include:
- Tailored legislation for ground ambulance services. Create specific laws based on the No Surprises Act, customized for ground ambulance services
- Standardized key definitions. Define terms like “community paramedicine,” “cost” and “ground ambulance emergency medical services” to ensure consistency
- Mandatory coverage for ground ambulance services. Require health plans to cover emergency ground ambulance services, regardless of network status
- Establishment of a federal advisory committee. Create a committee to advise on expanding coverage, supporting innovations, and addressing rising operational costs
- Prohibition of balance billing. Ban out-of-network balance billing for ground ambulance services and cap patient cost-sharing at the lesser of $100 or 10% of the bill
- Regulated rates with guardrails. Implement state or local regulated rates, with federal guardrails ensuring fair reimbursement that accounts for provider costs
- Billing transparency. Require detailed, transparent billing information and the use of the No Surprises Help Desk for disputes
- Timely payments for providers. Set a 30-day timeline for insurers to process payments or denials, with penalties for delays
The report outlines comprehensive recommendations aimed at preventing out-of-network ground ambulance balance billing and ensuring fair, transparent payment processes for both patients and providers.
The report is critical because it directly addresses the long-standing issue of out-of-network ground ambulance balance billing, which has financially burdened countless patients. By recommending specific legislative changes and guardrails for payment systems, the report seeks to ensure that patients are no longer left responsible for payment to ambulance providers.
For ambulance providers, the recommendations offer much-needed clarity and a fairer system of payment. Establishing regulated rates, enforcing prompt payments from insurers and including penalties for delays means providers are more likely to receive timely and reasonable compensation. This, in turn, enhances financial stability and operational efficiency for ground ambulance services, allowing them to focus on delivering high-quality care, rather than navigating billing disputes. Simultaneously, patients benefit from the cost-sharing protections and transparency measures, reducing confusion and financial distress while ensuring they receive critical care without the fear of overwhelming debt.
The issue: Out-of-network ambulance billing
Balance billing occurs when patients are charged for the difference between what an out-of-network ground ambulance provider bills and what the insurance company agrees to pay. Often, patients are left with substantial unexpected bills following emergency medical situations, causing financial hardship.
This terminology has often been misquoted as “surprise billing,” although there has never been a surprise that a payment would be required for a service rendered. The GAPB Committee’s report outlines a multi-faceted approach to address this issue and prevent such billing practices while ensuring fair compensation for ambulance providers.
| More: A billion dollars of savings: The legacy of ET3. Matt Zavadsky discusses the CMS disclosure and the latest in the move to fund treatment in place
Framework for ground ambulance legislation
A central recommendation of the report is that while the No Surprises Act provides a foundation, specific legislation for ground ambulance services is required. The committee suggests that consumer protections, such as price comparison tools, directory information and enforcement authority, can be maintained from the Act. However, ground ambulance services require unique provisions to reflect their operational challenges.
To ensure clear application of the recommendations, the committee proposed standard definitions for several key terms:
- Community paramedicine. A practice involving the provision of person-centered care in diverse settings, aimed at improving health outcomes through integrated care teams.
- Cost. Defined according to the Medicare Ground Ambulance Data Collection System (GADCS), including labor, facilities, vehicles, equipment and other costs.
- Ground Ambulance Emergency Medical Services. Ambulance services provided to individuals who reasonably believe they have an emergency medical condition.
These definitions help standardize the expectations for ground ambulance services, offering a clear structure for legislative and policy implementation for the following recommendations.
1. Expanding coverage of ground ambulance services
One of the most significant recommendations is to require health (insurance) plans to cover ground ambulance emergency medical services, regardless of whether the provider is in-network. As EMS and ambulance providers know, services operate in a given first-due, zone or exclusive operating area and do not seek patient insurance details when a 911 call is received, looking after the patient no matter their insurance category.
This recommendation mandates that plans must cover emergency services without prior authorization and without imposing network-related restrictions. Whether or not an ambulance provider is in-network should not affect the patient’s access to these life-saving services.
2. Creation of a federal advisory committee
To ensure ongoing evaluation and improvement of ground ambulance reimbursement policies, the committee recommended forming a federal advisory committee. This body would advise on expanding ambulance coverage beyond hospital transports, supporting innovations such as community paramedicine, treatment in place and alternative destinations. Additionally, the advisory committee would address the rising costs of ancillary supplies and medical equipment, further ensuring ground ambulance services’ long-term viability.
3. Prohibiting balance billing
At the heart of the report is the prohibition of balance billing for out-of-network ground ambulance services. The committee proposes a series of recommendations to regulate the rates that insurers pay ambulance providers, while setting cost-sharing caps for patients. Under this proposal, patients would only be required to pay the lesser of $100 or 10% of the total ambulance bill, with the rest covered by insurance. Any payments made by the patient would count toward in-network deductibles.
4. Setting guardrails for regulated rates
One of the report’s crucial recommendations is that state or local regulated rates for ground ambulance services should be adopted through transparent, public processes. Congress should establish minimum guardrails for these regulated rates, ensuring they account for ambulance providers’ operational costs and revenue mix. These guardrails would include a public process for evaluating rates and setting reimbursement amounts annually.
Additionally, the committee recommends the establishment of a publicly available federal database that details regulated rates by locality, making it easier for consumers and providers to access this information.
5. Billing transparency and timeliness
The report also focuses on the transparency of the billing process. Ambulance providers must wait until after insurance claims are submitted before billing patients. Additionally, all ambulance bills should include information about the insurance determination, any patient obligations and how to dispute the charges if necessary. The committee further suggests directing patients with billing concerns to the No Surprises Help Desk for assistance and dispute resolution.
6. Ensuring timely payments
To reduce delays in provider payments, the report outlines strict timelines for payment processing. Insurance companies must issue payment or a denial notice within 30 days of receiving a bill, with penalties for non-compliance. This ensures ground ambulance providers receive prompt compensation for their services.
A step toward fairness
The GAPB Advisory Committee’s report is a critical step in addressing the long-standing issue of out-of-network ground ambulance billing. By recommending a balanced approach that safeguards patients from financial distress while ensuring ambulance providers are fairly compensated, the committee’s proposals aim to enhance transparency, improve access to care and reduce unnecessary costs.
If these recommendations are adopted by Congress, patients will benefit from increased protections against surprise bills, and the ambulance industry will see clearer guidelines for compensation. The goal is to strike a balance between patient affordability and provider sustainability, ensuring that emergency ground ambulance services remain accessible and fair for all.
EMS1 is using generative AI to create some content that is edited and fact-checked by our editors.
