Nearly 60% of ground ambulance rides in 2022 were out of network, according to an analysis by FAIR Health first provided to Axios.
The report, “A Window into Utilization and Cost of Ground Ambulance Services: A National Study of Private Healthcare Claims,” sourced its data from a 42 billion private health claims records, showing only a slight decline of out-of-network ambulance rides from 2018 to 2022 (63.7% to 59.4%, respectively).
The FAIR Report presents interesting data, but notably lacking is the reasons for out-of-network status of ambulance claims. Likely reasons cited by ambulance agencies have included:
- Lack of interest by insurers to contract with ambulance agencies, citing < 1% of the payer’s spend is on ambulance services and they are focused on providers that represent larger % of their spend.
- Low in-network reimbursement rates offered by insurers, well below the cost-of-service provision.
- The basic in-network model (lower fees in return for higher volume (i.e.: more efficiency) does not work for primarily 911 providers (911 calls represent most out-of-network claims))
- Many public EMS agencies lack the desire to become in-network providers.
Notable excerpts from the FAIR Health report:
- “In addition to being used for transport, ground ambulances can provide on-site treatment, without transporting the patient from the original location to a hospital. Such treatment increased from 2018 to 2020, rising from 1.4 percent to 2.0 percent of all ground ambulance claim lines, but decreased slightly in the following years, dropping to 1.9 percent by 2022.”
- “From 2018 to 2022, response and treatment without transport accounted for a higher percentage of ground ambulance claim lines among individuals aged 19 to 35 than any other age group: between 2.2 and 3.1 percent. By comparison, the age cohort 65 years and older had the lowest percentage.”
More agencies may be finally billing for Treatment in Place (TIP), but the CMS COVID waivers may have impacted this statistic. Also notable, the data does not include Medicare FFS claims.
In addition to the staggering out-of-network findings, CPSM’s EMS subject matter expert Matt Zavadsky identified some other key takeaways from the data in the report:
The average allowable fees in these states are below the national average COST of providing service, according to cost report data from the Public Consulting Group.
We may need to do a better job of documenting clinical impressions to reduce the number of “General Illness” claims.
Only about 30% of the patients under 65 transported to the ED by ambulance were admitted to the hospital. Can we do something other than transport to the ED with the other 70% of the patients?