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Ambulances are often called upon at a moment’s notice, usually because someone is injured in a car crash or because they hear about an accident on the radio or from police or bystanders. And while ambulance crews are typically well-intentioned, the medical bills that follow can be a real shock.

A report last year from the U.S. Department of Health and Human Services found that more than half of all ambulance rides resulted in an out-of-network charge. The same report found that only 6% of private insurers were in-network with most ambulance providers. This gap between negotiated rates and what your insurance company actually pays is known as balance billing, and it’s common with both private ambulance companies and Medicare-funded ones.

The report also pointed out that most states have no laws regulating ambulance charges, while others have regulations in place that can prevent surprise medical bills. The most important protections are in place for air ambulances, which must be billed at in-network rates and can’t balance bill. But there’s a gap in coverage for ground ambulances, which are more common and can leave you with big bills.

While the national average is $3,200 for a single trip in an ambulance, some patients have been hit with bills that top $10,000. These bills can be a result of fraud or simply the result of a system that allows ambulance providers to charge whatever they want, with no scrutiny or oversight.

Ambulance bills are complicated, and the most common reason for a surprising ambulance bill is that the ambulance crew was out of network. Many of these services are operated by for-profit or not-for-profit organizations that contract with local towns and cities to respond to 911 calls. Other ambulance services are run by municipal governments or volunteer fire departments.

Many of these for-profit or not-for-profit companies have aggressive billing practices, and a slew of complaints to the Better Business Bureau has prompted some states to investigate. But it’s important to remember that the number of complaints about ambulance billing is relatively small compared with those against hospitals, physicians, dentists and other healthcare providers.

Whether you’re being transported by an out-of-network ambulance or are billed for a service you didn’t need, if the bill is too high, it’s important to take action. This could mean contacting the billing department to dispute your charges or seeking a payment plan. But it could also mean calling your state’s attorney general or the Consumer Financial Protection Bureau.

The Hawkins were left with a $2,438 bill from AMR. A spokesperson for the company said they are working with them to reduce the amount and that a financial assistance program will be available soon. But they’re still stuck with a huge bill, and they’re not alone: According to a study published in 2019, 79 percent of ground ambulance rides could result in an out-of-network balance owed by the insured, or even exceed their annual deductible. American Medical Response Billing