Federal law protects many patients from surprise emergency-room bills and even out-of-network air ambulances. Ground ambulances remain a major exception — and Tennessee came one Senate committee vote from changing that in 2026.
By Brandon L. Burley
The Redemption Project Newsroom | Follow the Dollar / Systems Explained
Chest pain does not leave much time for comparison shopping.
Neither does a stroke.
A seizure.
A child struggling to breathe.
Someone calls 911.
An ambulance arrives.
Nobody asks the paramedic whether the ambulance company participates in their insurance network. Nobody checks an app for mileage rates or asks the dispatcher for a cheaper provider.
The patient gets in.
The ambulance goes to the hospital.
Then the bill arrives.
And here is one of the stranger gaps remaining in American health-care law:
Federal law generally protects people with most private insurance from many unexpected out-of-network charges at the emergency room.
It also protects them from surprise bills involving out-of-network air ambulances.
The ground ambulance that carried them there is generally excluded.
The Centers for Medicare & Medicaid Services says ground ambulance services are not covered by the No Surprises Act’s billing protections unless another law, such as state law, provides protection.
The helicopter can be protected.
The emergency room can be protected.
The ambulance driving down the interstate may not be.
One ride can produce several prices
Suppose an ambulance company bills $1,500.
That does not necessarily mean $1,500 is what the insurer believes the service is worth — or what the provider normally collects.
The provider has a charge.
The insurer may recognize an allowed amount.
The insurer pays according to the health plan.
The patient may owe a deductible, copayment or coinsurance.
And if the ambulance provider is out-of-network, another number can appear.
A balance bill is the difference between what a provider charges and what the health plan recognizes or pays, when the provider is permitted to seek that remaining amount from the patient.
That places the person who called 911 between two sophisticated institutions.
The ambulance provider says reimbursement is too low.
The insurer says the charge is too high.
The patient is holding the bill.
Tennessee almost changed that in 2026
This year, Tennessee lawmakers considered legislation aimed directly at that problem.
House Bill 1061 and Senate Bill 1376 would have prohibited covered patients from being balance billed for qualifying out-of-network ambulance services.
The Tennessee House passed its amended version 94-0 on April 2.
Five days later, the Senate Commerce and Labor Committee considered the companion bill.
The vote was 4-5.
It failed.
One committee vote separated Tennessee from a significant change in ambulance billing.
The House version would have protected covered patients from additional payment responsibility beyond applicable deductibles, coinsurance or copayments while creating rules governing what health insurers would owe ambulance providers. TennCare, CoverKids, state employee group plans and air ambulance services were excluded from the amended measure.
That second part is why this debate is more complicated than simply banning an unpopular bill.
If the patient no longer pays the disputed difference, somebody still has to decide what the ambulance service should receive.
An ambulance is selling readiness as much as transportation
An ambulance is not a taxi with medical equipment.
The system costs money before anyone calls.
Vehicles have to be purchased and maintained.
Equipment has to be stocked.
Paramedics and EMTs have to be trained and available.
Medications can expire unused.
Dispatch has to function.
An ambulance sitting at a station at 2 a.m. is still costing money.
That creates what might be called the readiness problem.
Communities do not merely pay for miles driven.
They pay for the ability to have trained people and equipment ready when the next emergency happens.
And new federal data show how dramatically those economics can vary.
Low-volume ambulance systems face a very different calculation
In June, the Medicare Payment Advisory Commission released its assessment of newly collected federal ground-ambulance cost data.
Its clearest finding was that transport volume was the strongest driver of cost per transport.
Ambulance organizations in the lowest quarter by transport volume averaged $2,878 in cost per transport.
Those in the highest-volume quarter averaged $918.
Across all organizations, MedPAC found even wider variation: cost per transport was $367 at the 10th percentile and $4,136 at the 90th percentile.
That helps explain why ambulance pricing cannot be understood simply by comparing what two patients were charged.
A high-volume urban system can spread the cost of staffing, stations and equipment across thousands of transports.
A smaller or geographically isolated service may maintain much of the same readiness for far fewer calls.
The patient sees one ambulance ride.
The provider has to finance all the hours when nobody was riding in it.
That does not make every ambulance bill reasonable
Real operating costs do not settle every billing question.
A high charge is not automatically justified because ambulances are expensive.
An insurer’s lower payment is not automatically reasonable because the provider’s bill looks high.
And a patient should not become the default financing mechanism when those two sides disagree.
The federal government has already recognized the problem.
The No Surprises Act created a Ground Ambulance and Patient Billing Advisory Committee specifically to examine ambulance charges, insurance coverage and ways to protect consumers from balance billing. The committee issued its final recommendations in 2024.
Congress protected patients from many other surprise emergency bills.
Ground ambulance billing remains unfinished business.
There is almost no normal market here
This is what separates a 911 ambulance from most purchases.
If a hotel is too expensive, you can choose another hotel.
If a restaurant charges too much, you can leave.
A person having a possible heart attack cannot reasonably ask:
“Before we go, which ambulance company has the best negotiated rate with my insurance carrier?”
Sometimes the patient is unconscious.
Sometimes a bystander made the call.
Sometimes there is only one practical provider.
The service happens first.
The price becomes clear later.
That is almost the reverse of an ordinary marketplace.
Follow the dollar
That leaves Tennessee with a useful reporting question after the 2026 bill failed.
What are ambulance companies actually charging?
What are insurers actually paying?
How much do local taxpayers already contribute?
How much does Medicare pay?
How much is never collected?
How often are insured Tennesseans balance billed?
And how large are those bills?
Those numbers would tell us whether the disagreement is primarily about excessive charges, inadequate reimbursement, expensive emergency readiness — or some combination of all three.
The patient should not have to decide that while calling 911.
That is the point.
The ambulance needs to come.
The paramedics need to provide care.
The hospital needs to be reached.
The argument over money can happen afterward.
But that argument should be between the institutions capable of having it.
A medical emergency is already enough of an emergency.
The bill should not become another one.
And if Tennessee revisits the issue, the public should be able to see exactly what one ambulance ride costs, who pays for it and where every dollar goes.
That is why we follow the dollar.
I am a retired detective and criminal justice / government educator based in Tennessee. I founded The Redemption Project, as a place to focus on civics, rebuild non-partisan trust, and provide educational and emotional grace while learning about the news. I also have a column in Knox TN Today. My reporting and commentary have also appeared in other outlets including; Governing, The Arizona Capitol Times, South Florida Sun Sentinel, Police1, among other state and regional outlets.
