Emergency room doctors say insurers are increasingly declining to cover costly air-ambulance rides for critically ill patients, claiming they aren’t medically necessary. And the National Association of EMS Physicians says the No Surprises Act, enacted in 2022, is partly to blame.
The law protects patients from many out-of-network medical bills by requiring insurers and providers to haggle over fair payment. But insurers can sidestep the law if they determine care is “not medically necessary” — and insurers themselves get to decide what that means.
In the fall of 2022, Sara England of Salinas, Calif., learned about this firsthand when ER doctors at a hospital in her town had her 3-month-old, Amari, transferred by air to the University of California at San Francisco Medical Center for what turned out to be an RSV infection. Her insurer, Cigna, determined the baby’s plane ride wasn’t necessary because his medical records didn’t show a ground ambulance would “impede timely and appropriate medical care.”
(Ground ambulances are exempt from the No Surprises Act.)
England is on the hook for the full cost of the air-ambulance ride: more than $97,000. “I thought there must have been a mistake,” England said. “There’s no way we can pay this. Is this a real thing?”
Cigna spokesperson Justine Sessions called the bill “egregious” and said, “We are working diligently to try to resolve this for the family.”
The emergency physician association said it frequently encounters denials like England’s. The group wrote to Health and Human Services Secretary Xavier Becerra, acting labor secretary Julie Su and Treasury Secretary Janet L. Yellen in February urging the federal government to require insurers to presume medical necessity for air-ambulance use, subject to retrospective review.
“Clinical determinations made by a referring physician (or another qualified medical professional) should not be second-guessed by a plan,” read the letter from José Cabañas, the group’s president. The Association of Critical Care Transport has made a similar request.
HHS spokesperson Sara Lonardo said the agency is committed to strengthening protections in the No Surprises Act.
Insurers point the finger at air-ambulance providers. Robert Traynham, a spokesperson for industry group AHIP, said providers often don’t submit medical records, impeding a full evaluation. He said AHIP also suspects that air-ambulance companies sometimes favor more distant hospitals that contract with them over closer facilities.
The air-ambulance industry — much of it controlled by private equity firms — is known for fast-growing prices, limited in-network contracting and surprise out-of-network bills averaging nearly $20,000. And the Centers for Medicare and Medicaid Services data shows that when insurers and providers go head-to-head in No Surprises arbitration, 8 in 10 cases are settled in the provider’s favor, incentivizing them to raise prices higher.
Lack of medical necessity is cited in the bulk of air-ambulance claims denials, said Loren Adler, who studies the industry for the Brookings Institution.
More than a year later, England is still fighting her bill. “I don’t know what else to do other than to be a squeaky wheel and make as much noise about it as possible, because it’s not right,” she said.
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