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It's not just air ambulance costs that have skyrocketed in recent years -- ground ambulance costs also have accelerated, according to a study of U.S. private healthcare claims.

The average allowed in-network amount for advanced life support (ALS) emergency ground ambulance transport rose 56%, from $486 in 2017 to $758 in 2020, according to a white paper from the non-profit .

The increase was part of a general rise in costs (not including mileage fees) for both ALS and basic life support (BLS) emergency ground ambulance transport during the period, the report stated, and included upticks in average allowed amounts for privately insured patients -- the total fee negotiated between an insurance plan and a provider for an in-network service -- and average billed charges, or the amount charged to a patient who is uninsured or obtaining an out-of-network service.

Costs for ALS services were higher than those for BLS services across the spectrum, FAIR Health said.

In addition, ALS emergency ground ambulance services increased from an average charge of $1,042 in 2017 to $1,277 in 2020 for a nearly 23% jump. And the average allowed amount for BLS emergency ground ambulance services increased nearly 40% from $373 to $522 during the same period. The average charge for BLS services rose 17.5% from $800 to $940.

The report pointed out that "COVID-19 accounted for 2.1% of BLS ambulance claim lines in 2020, entering the rankings in 10th place that year."

Also, in 2019 and 2020, the five states with the highest emergency ground ambulance use as a percentage of all medical claim were in the Northeast and South, while the five states with the lowest use were in the Midwest and West.

Currently, no federal law protects consumers against surprise bills from out-of-network ground ambulance providers, according to the report. While some state and local governments regulate ground ambulance surprise billing practices, such laws may have limitations in terms of which health plans or ambulance providers they apply to, it stated. In July 2021, the Department of Health and Human Services announced , including out-of-network emergency transport.

"Ground ambulance services have been the subject of substantial policy interest," FAIR Health President Robin Gelburd said in a statement. "We hope that this study of ground ambulance transport proves useful to policy makers, researchers, payors, providers and consumers seeking to better understand this component of the healthcare system."

The report noted that people ages 65 and older were consistently the largest age group associated with such services. However, their share decreased from nearly 38% in 2016 to 34% in 2020. "General signs and symptoms" were the most common diagnosis tied to emergency ground ambulance in the study period, followed by general signs and symptoms involving the circulatory and respiratory system, and signs and symptoms involving cognition.

Additionally, males experienced a higher percentage of inpatient admissions after emergency ground ambulance transport versus females in all age groups except those ages 0 to 18 years. In the latter age group, 35.4% of females were admitted to the hospital versus 32.3% of males.

The report also stated that the average Medicare Advantage (Part C) amount for ALS services -- as opposed to that for privately insured patients -- increased only ever so slightly, from $441 in 2017 to $463 in 2020, representing just a 5% increase. The average Medicare amount for BLS services rose just under 5%, from $372 to $390.

The study was done using data for privately insured patients covered by insurers and third-party administrators. The latter voluntarily participate in FAIR Health's data contribution program, according to the report. Claims data from January 2016 through June 2021 were evaluated. While Part C enrollees from contributing insurers were included in the analysis, Medicare Parts A, B, and D, participants were not.

The report explained that BLS "can be provided by either a paramedic or an emergency medical technician ," while ALS "must have a paramedic on board. ... Typically, to treat a patient during an ALS ambulance service, an invasive procedure is done. ... An ALS provider can give injections, do very limited surgical procedures...and administer medicine. ALS ambulances are typically outfitted with airway equipment, cardiac life support, cardiac monitors and glucose testing devices."

Study limitations of the non-longitudinal analysis included its observational nature and the lack of peer review.

In 2021, FAIR Health released a report on a the, based on private and Medicare services. At the time, FAIR Health noted that because air ambulance transport is often used for patients in life-threatening situations, they generally have no control over type of transport or provider used. As a result, for transport occur frequently.

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