Ground ambulance bills are the largest source of unexpected out-of-network medical bills according to research by Christopher Garmon, a health economist at the University of Missouri-Kansas City. His research showed that “[i]n more than half of cases involving ambulance transportation, the ambulance services were out of network […].” Over 50% of ground ambulance rides end with a balance bill. For insured patients, according to Betsy Imholz, special projects director at the Consumers Union, “[t]he core problem is that ambulance and private insurance companies often can’t agree on a fair price, so the ambulance service doesn’t join the insurance network. That leaves the patients stuck in the middle with out-of-network charges that are not negotiated.” 
Despite being a significant source of surprise medical billing, none of the proposed federal legislation on preventing surprise medical bills addresses bills generated by ground ambulances. Why not?
In a recent article in the New York Times, several reasons are offered as to why ground ambulances are excluded from the discussion:
- Ground ambulances can be regulated by the states and, therefore, are subject to public oversight (an argument made by opponents to regulation). Sen. Lamar Alexander [R-Tenn] stated to the Times that “[u]nlike air ambulances, ground ambulances can be regulated by states and Congress should continue to learn more about how to best solve that problem.” While this may be true on the surface, the states are not regulating surprise billing resulting from ground ambulance transport. Anthony Wright, executive director of Health Access California, worked on a 2016 California law to restrict surprise billing and believed it made sense to include ground ambulances. The idea was met with resistance and the legislation as passed did not regulate ambulance pricing. Colorado comes the closest by passing legislation that requires a committee to study ambulance billing. No other state has enacted surprise billing legislation that addresses ground ambulances.
- Local governments would lose needed revenue.
- “It’s hard to go after an entire industry at once” as stated practically by Mr. Wright. Sen. Lamar Alexander [R-Tenn] suggests the same in his statement to the Times that surprise bills from air ambulances is a more pressing issue. 
Ultimately, Congress is picking and choosing its battles. While we may see more states and the federal government start to study these issues, it seems unlikely we will see any legislation regulating ground ambulance surprise billing in the near future.
 One in Five Inpatient Emergency Department Cases May Lead to Surprise Bills, Christopher Garmon and Benjamin Chartock, Health Affairs Vol. 36, No.1: Coverage Expansion, Accountable Care & More