The report is the latest probe of an industry offering life-saving services – often a helicopter ride from the scene of critical injury to a hospital – that, critics say, can leave patients financially crippled.
According to the GAO, first responders and physicians determine which air ambulance provider to call based on proximity or relationships, often without regard to a patient’s insurance plan, leaving many of those who are privately-insured with massive “balance bills,” or charges left to patients after private insurance is applied.
While few Americans will need an air ambulance transport, the report reads, “those patients who do generally have no control over the decision to be transported by air ambulance or the selection of the air ambulance provider.”
Air ambulance providers and insurers the GAO interviewed saw a lot of out-of-network transports in 2017, but some say they’ve been seeing a recent uptick in network contracts. For example one large independent provider and a national insurer signed a contract covering patients in five states as of August 2018.
A spokesperson for the American Association of Air Medical Services stands by the industry standard of requesting the closest air ambulance services available – regardless of whether it is covered by a patient’s insurance plan.
“It is unconscionable to think that either the requesting physician or medically-trained first responder should try and determine who insures a patient or what that insurer may cover, or if that insurer has a contract with the responding service, during a medical emergency,” the spokesperson told ABC News.
A 2016 ABC News investigation into the industry found that some patients were left with little recourse after receiving five-figure bills they could not pay. In many instances, patients’ insurance paid for a portion – but not all – of the amounts charged by the air ambulance companies. In some cases, those accounts were sent to debt collection, using what some patients told ABC News were aggressive tactics and which crippled them financially.
The GAO has previously called for improvements in pricing disclosures to consumers in light of these hefty price tags, but their recent report found that the median prices charged for air ambulance services have only continued to rise.
It is difficult to assess the full scope of the balance billing, the report notes, because there is a lack of comprehensive national data on the issue – an issue the GAO also flagged in its 2017 report.
In its latest report, the GAO analyzes the most recent numbers available: a private health insurance data set for air ambulance transports that includes information on network status and prices charged (before insurance) in 2017. But it may not represent all private insurers, according to the GAO.
The report also draws from interviews with officials in Florida, Maryland, Montana, New Mexico, North Dakota and Texas – chosen for geographic distribution and the states’ varied approaches to limit balance billing. The GAO also interviewed air ambulance providers, health insurers and officials from the Centers for Medicare & Medicaid Services and Department of Transportation.
In an attempt to understand the magnitude of balance billing, the GAO turned to two states that recorded consumer complaints on specific incidents of balance billing from 2014 to 2018: Maryland and North Dakota.
In Maryland, about two dozen complaints were filed regarding balance bills, which ranged from $12,300 to $52,000. In North Dakota, three dozen complaints specified balance bills ranging from $600 to $66,600.
Insurance companies note that patients may not pay these in full if they reach agreements with their air ambulance providers and/or insurers.
One air ambulance provider said patients can receive up to 50% off a bill if the patient agrees to pay the other 50% immediately. Other patients opt to offer the provider detailed financial information in return for a potential discount or payment plan.
But this process is a long one, and one air ambulance provider told the GAO that patients who fail to respond to communications may face a collections process. Data provided by some providers showed that, even with discounts, patients still pay bills that reach into the thousands.
In 2017, the report notes, the median price charged for a helicopter transport was $36,400, and the median price charged for a fixed-wing transport was $40,600. This represents an increase of 60% from 2012, when the median price charged for a helicopter transport was $22,100 and the median price for a fixed-wing transport was $24,900.
There is currently no federal regulation on private insurance billing as it relates to air ambulance transports.
In 2018, President Trump signed the Federal Aviation Administration Reauthorization Act, which required that the Department of Transportation, along with the Department of Health and Human Services, create an advisory committee to research and implement better ways to inform patients of charges and improve the disclosure of insurance options related to air medical services.
The department is continuing to review applications to join the committee.