Keith Ventimiglia was home in Brimfield with his family two years ago when he suddenly couldn’t move, overcome with extreme pain. His wife called 911 and an ambulance took him to the nearest hospital about 16 miles away.
Not much about an ambulance ride would surprise Ventimiglia; he’s worked for decades in emergency medicine and is now a part-time paramedic. But he got stuck with a $6,800 bill just for the ambulance ride.
The bill from Action Ambulance Service Inc. was greater than the cost of his emergency room visit and follow-up tests.
Ventimiglia didn’t worry: He sent the bill to his insurance company, UnitedHealthcare, assuming “things would be taken care of.”
That one bill would eventually land him in small claims court. Twice.
Ventimiglia says he’s healthy now, and he’s grateful for the medical care. But he is among about 300 people been sued by Action Ambulance in Massachusetts’ state courts for debts since 2020, according to data obtained by the GBH News Center for Investigative Reporting and analyzed by Boston University data students. Those lawsuits represent just a small fraction of people saddled with ambulance debt across the state.
When someone calls 911, many people don’t understand that an ambulance ride could cost them. If you have private insurance in Massachusetts, it’s likely that the ambulance provider is out of network and insurance won’t pay the entire amount.
Millions of dollars of ambulance debt in Massachusetts are sent to collections every year, state records show. It’s a major gap in regulations aimed at keeping consumers from getting “surprise” emergency medical bills, with experts telling GBH News that there is no protection against steep fees for emergency transport. Then, for the few whose debt ends up in small claims court, most don’t show up and are ordered to pay in full.
Ambulance companies and insurers usually don’t agree on how much ambulance services should cost. Most ambulance companies, whether private or city-run, say insurance rates don’t cover their high operating costs, so they avoid signing contracts with insurers and remain “out of network.”
So, after an emergency, people end up playing mediator between their insurance company and the ambulance provider to try to settle the bill — and can end up responsible for whatever is left.
Do you have an ambulance billing story of your own? Email GBH News’ investigative team at investigations@wgbh.org.
One-mile ride, thousands in debt
Massachusetts residents are struggling with unexpected ambulance debts, learning firsthand how costly those emergency transports can be and what a nightmare they are to tackle.
Nearly 31,000 accounts — totaling nearly $27.5 million — were sent to collections by four private ambulance providers for services provided in 2022, according to a report by the state attorney general’s office.
GBH News spoke to over a dozen people with ambulance debt — including a teacher, a nurse and even a medical billing manager — all shocked at the vast gap between what the ambulance company had charged and what their insurance company paid.
Some agreed to pay off their debt in installments stretched out over years. Others spent months learning the intricacies of billing to whittle down debt, or ended up paying with a credit card in a courthouse hallway.
Like Rebecca Kelly. Action Ambulance took Kelly to small claims court when she refused to pay thousands for a one-mile ambulance ride for her son.
Kelly says her son’s father took him to an urgent care after he hyperventilated at wrestling practice. From there, he was told he needed to be taken by ambulance to a nearby hospital.
The hospital found no major issue, Kelly said, and sent her son home. But then she received a $6,500 ambulance bill for the ride.
“I was astounded,” Kelly said “How could it cost so much for a one-mile ride?”
Kelly was soon ping-ponging between Action Ambulance and her insurance company, Cigna Healthcare, trying to get the bill resolved. Cigna has no contract with Action, so there are no agreed rates for reimbursements. Cigna did not respond to GBH News’ questions.
Kelly says she eventually received two insurance payments, but was left with a $3,400 balance that the insurer refused to cover.
So, in July, Action took her to small claims court.
Data shows Action was one of the most active ambulance companies in small claims court during that time. The median claim was about $3,400, according to a GBH News review of cases.
Kelly pushed aside her anxiety and decided to fight her bill.
In late September, Kelly took a day off from her work as a manufacturing supervisor to go to Woburn District Court — where she found herself surrounded by others hauled into court for all kinds of consumer debt.
A clerk magistrate told Kelly to negotiate with Action’s collections manager Charles Coolidge, who travels the region using small claims court as a lever to recover payments.
“I think it’s an exorbitant amount for an ambulance for one mile,” Kelly said to Coolidge in the hall outside court.
“Anything that’s a balance after insurance becomes a patient responsibility or parent responsibility,” Coolidge told her.
“If it’s too high, we can work with you and try to get it squared away,” he added.
The two haggled for a bit until they agreed on $1,700 — half of what Action took her to court for. Kelly pulled out her credit card in the hall and handed it to Coolidge. Her debt would be cleared, he said.
Coolidge declined to be interviewed.
Outside court, Kelly was still in disbelief.
“If you need an ambulance, you shouldn’t have to go to small claims court, a year and a half later, to settle your bill,” Kelly told GBH News outside court.
Most people who are sued for consumer debt don’t appear in court at all because they are frightened, don’t understand the process or don’t receive notice of the hearing, consumer advocates say.
And few people know they don’t have to negotiate, and do have the right to a trial where they could contest the cost, said Alexa Rosenbloom, who leads the Consumer Protection Clinic at the Legal Services Center of Harvard Law School.
In those trials, the defendant can challenge the charges on a bill and introduce witnesses or evidence, and the plaintiff has to prove why they can charge the patient that amount.
Rosenbloom said many take the option like the hallway negotiation because they are eager to get through the process quickly, and have to back to work or child care.
“It feels inherently coercive,” she said. “It’s tipping the scale in one direction.”
Scalded by the experience, Kelly now tells people to avoid ambulances if possible.
“Honestly? Now that I know how expensive they are, I would say if you can get to the hospital yourself, just do that,” Kelly said.
I got a high ambulance bill. What should I do?
- Make sure your ambulance provider has your insurance information and bills insurance first.
- Ask for an itemized bill from the ambulance company. Dispute incorrect or out of network charges that are too high. Check rates for comparable services in nearby municipalities.
- Talk to the ambulance company about reducing the bill, and explain any hardships.
- Contact your insurance company to see if they’ll negotiate.
- It may help to bring the two parties together.
- Call your local lawmaker to explain your billing issue. You can find their name and information here.
- If you believe you're a victim of fraud or predatory behavior, contact the attorney general’s office.
Source: Consumer advocates interviewed by GBH News
‘It’s a broken system’
Ambulance companies say their finances are stretched to the breaking point.
Most municipalities in Massachusetts, including Boston, run their own emergency ambulance services, and some contract with private ambulance companies or use a mix.
But whether or not it’s a private company, they bill insurance holders for whatever the insurance company won’t cover.
Lawsuits are often the last resort.
Action CEO Michael Woronka told GBH News that the lawsuits are a “very, very small percentage” of the company’s roughly 30,000 transports each year in New England.
He defended his rates. If his company can’t recover the money, he said, then cities and towns would have to pay more to keep them operating.
“Our cost structure is going up at a rate that’s enormous,” he said. “The hoops that we have to jump through to process claims drives the cost up as well.”
Taking people to court makes sense for Action, he says: According to Woronka, about three-quarters of cases result in some kind of debt payment.
“It’s very efficient for us,” he explained.
Other ambulance companies say they don’t usually resort to the courts, but they do struggle to get their expenses paid.
In Fall River, Bethann Faunce has spent three decades working for the city’s Emergency Services — and, now, she’s the city’s EMS chief and oversees its ambulance service. Faunce is frustrated by what it takes to get insurance companies to pay for every single ambulance transport.
She calls ambulance billing “a broken system.”
“It is a lot of work to have to fight — when you’re doing 30,000 ambulance calls a year — for every single claim, that they [insurance companies] try to send you a 40% payout,” Faunce said. “You have to call, and you try to negotiate with them to try to get them to send you more money.”
She said Fall River EMS doesn’t send bills to collections or sue people, but they do send out letters with bills asking people to try to get more from their insurance companies.
“If they [insurance companies] would just come to some modicum of a reasonable payment,” Faunce said, “that would take that patient out of the middle.”
Nearly 80% of municipal ambulance providers are not in-network with any commercial health plan in the state, according to the state attorney general’s office report.
Faunce and other ambulance operators said part of the problem is Medicare and Medicaid reimbursement rates.
In Fall River and many other communities in Massachusetts, the majority of ambulance users are insured through Medicare or Medicaid. But providers say those government reimbursement rates fall far below the actual cost of providing care — which means they couldn’t survive without the higher rates paid by the privately insured.
Like other health care providers, Faunce said, they’ve struggled with rising costs for equipment and medication. And there’s a shortage of the skilled labor needed to staff ambulances, too.
‘No protection whatsoever’ in an emergency
Unregulated ambulance billing leaves consumers exposed to unpredictable bills.
Ambulance bills consistently show up in the medical debt cases seen at the Boston-based nonprofit Health Law Advocates, said Wells Wilkinson, a senior attorney.
The billing amounts “vary drastically” among companies, he and others said, largely because pricing is not regulated by state or federal law, rates are linked to call volume and insurance reimbursement rates vary widely.
“It’s the one area where consumers in an emergency literally have no protection whatsoever,” Wilkinson said.
State regulators have held some to account. In 2020, the Massachusetts attorney general announced a $1.6 million settlement with a Lowell ambulance company over allegations that consumers had been threatened with jail over their debts.
Insurers and ambulance companies fault each other for the chaotic system.
Ambulance companies say insurance reimbursement rates are too low.
“More ambulance companies are choosing not to contract with commercial insurance because the rates just don’t support the services that are being provided,” said Dennis Cataldo, CEO of Cataldo Ambulance Service and president of the Massachusetts Ambulance Association, which represents over 30 private ambulance companies.
The state’s insurance trade group blames “bad actors” among ambulance companies for not striking those agreements.
“We need to rein in ambulance companies — privately owned ambulance companies. We have been seeing for several years a failure of many of the ambulance companies to contract with the health plans,” said Lora Pellegrini, CEO of the Massachusetts Association of Health Plans, which represents 13 health plans.
The ambulance association supports a bill in the state Senate that would set a minimum rate of reimbursement by private insurance. The association representing insurers, one of the top lobbyists on Beacon Hill, supports a bill that would require any out-of-network ambulance company to accept a default rate.
State legislation would help fill a federal gap: A federal law known as the “No Surprises Act,” which took effect in 2022, shields people from out-of-network emergency medical expenses. Air ambulances were included, but ground ambulances were left out.
Patricia Kelmar, who works at a Colorado-based national consumer advocacy group called the U.S. Public Interest Research Group, has watched the finger-pointing for years. She thinks it’s time for legislators to step in.
“We’ve been waiting for the market — the insurance market, the health care provider market — to solve this, and it hasn’t happened,’’ Kelmar said. “And that’s the appropriate time to look for regulation.”
So far at least 20 states prohibit ambulance companies from charging patients the balance beyond what their insurer covers, according to a recent report by the U.S. Public Interest Research Group. In July, New Hampshire became the first state in New England to set rates ambulance companies can charge insurers. Various bills to tackle the problem have languished in the Massachusetts State House.
But Congress will have to act in order to protect everyone from unwanted ambulance bills. The majority of workers in the United States are covered by self-funded, company-sponsored insurance — which is regulated by the federal government, not the states.
And there’s now added urgency to the problem: the looming impact of federal cuts and changes to Medicaid that could result in an estimated 180,000 people in Massachusetts losing their health coverage.
“People without health insurance in emergencies are going to be faced with a really difficult decision of, ‘Can I afford to call 911 and get an ambulance?’” said Harvard School of Public Health economist Benjamin Sommers.
Ventimiglia is a high school math teacher — plus, he’s worked in emergency medicine for decades. As a part-time paramedic, he knows the challenges facing the ambulance industry.
“I understand why ambulances have to bill what they do,” Ventimiglia said. “You’ve got to make sure that truck runs and you have qualified, well-paid people on that truck with good equipment.”
But a few months after his first bill, his insurance company UnitedHealthcare had only paid $1,000 and he was billed for a $5,800 balance. He soon found himself “stuck in the middle.”
UnitedHealthcare would not comment on Ventimiglia’s case, citing privacy law.
In March, Action took him to court for the original balance. Ventimiglia countersued — challenging both the accuracy of the bill and his responsibility to pay. The case was dismissed after both parties agreed to drop their claims, though the court told the parties to try to get further insurance reimbursement.
Months later, Action refiled a claim seeking further payment saying he’d violated the court’s terms, which Ventimiglia denied.
“They’re resorting to the court system to help them make money. I don’t think that’s the way it should work,” Ventimiglia said.
His case was dismissed again after the judge refused to revisit it. Standing outside of court, Ventigmilia was relieved, but now wants to see change in the system.
“I hope, if nothing else, we can move to a point where people aren’t being forced to make financial decisions every time they’re calling 911,” he said.
GBH News Investigative Editor Jenifer McKim and GBH News intern Azusa Lippit contributed reporting. Data collection for this story was provided by Civera. Data analysis was provided by student researcher Ta-Chi Lin through Boston University’s Faculty of Computing & Data Sciences’ SPARK! Program.
Do you have an ambulance billing story of your own? Email GBH News’ investigative team at investigations@wgbh.org.
