Patients whisked or transferred to hospitals by air ambulances face time-sensitive emergencies — from strokes to traumatic accidents — so whether the helicopter carrying them is in their insurance network isn’t usually a top-priority question.

Weeks later, many of these patients receive an unpleasant surprise: a bill demanding tens of thousands of dollars.

More than two-thirds of air ambulance rides in 2017 were out of network, according to a Government Accountability Office report from March. The median price for air ambulance transport in a helicopter in 2017 was $36,400, the GAO found. Even if insurance does cover some of that cost, a consumer can still face tens of thousands of dollars in unexpected bills for what’s left — a practice known as balance billing.

Congress is trying to address that as part of a broader effort to rein in so-called surprise medical bills, which patients receive for care their insurer won’t cover, either for emergency services or by providers they might not choose, like an anesthesiologist or radiologist, even when a patient is at an in-network facility.

Outrage over these medical bills has pushed the issue near the top of the political health care agenda, with President Donald Trump and key lawmakers seeking legislation this year to protect patients from them.

But despite bipartisan interest in stopping such surprise medical bills, the health care industry is divided over the best way to handle them. Part of that debate is whether to prohibit such billing for air ambulance services, also known as medical evacuation or medevac companies, the source of some of the most expensive surprise bills.

“When you’re talking tens of thousands of dollars, that increases the likelihood that people are falling into  medical debt and getting sent to collections,” said Adam Fox, director of strategic engagement at the Colorado Consumer Health Initiative, a nonprofit consumer advocacy group.

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Air ambulance companies counter that the average out-of-pocket payment for patients with insurance that covers an air ambulance ride is $300, according to a Wyoming Department of Health study.

The companies are aggressively campaigning against one proposal that could reduce their revenues —  a Senate bill approved by the Health, Education, Labor and Pensions Committee in July that would ban air ambulance companies from balance billing. It would require insurers to pay the median in-network rate to the provider in those cases, the same mechanism that insurers would pay other providers under the measure.

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A competing House bill approved by the Energy and Commerce Committee wouldn’t directly prohibit air ambulance providers from balance billing patients. Instead, it would require providers and insurers to provide data about costs and claims to the Department of Health and Human Services and the GAO.

Hitting the airwaves

Air ambulance companies want the Senate to drop the provision that applies to their services because they say insurance payments could be too low for many bases to stay open.

“There needs to be a better way of taking the patient out of the middle and sustaining the service,” said Chris Eastlee, vice president of government relations at the Association of Air Medical Services, a trade group.

The air ambulance industry, which has about 250 providers in the nation, is joining a burst of advertising by interest groups on the legislation.

The Colorado-based Global Medical Response, which provides both ground and air ambulatory services, said the Senate bill could make it difficult for patients to access its services. The company launched an $800,000 ad campaign in August in nine states, according to Federal Communications Commission data compiled by the Center for Responsive Politics.

The company’s move mirrors campaigns by doctors’ groups and other providers against the Senate proposal, which they say would require insurers to reimburse providers for out-of-network care at rates providers call stingy.

Addressing air ambulance payments is difficult because they fall between health and transportation regulations. The 2018 reauthorization of the Federal Aviation Administration established a task force to collect data on air ambulance and patient billing, which the Department of Transportation appointed members to last month.

The air ambulance industry is urging lawmakers to take the slower approach of waiting for cost data. The companies note that several GAO reports say there’s no data available to guide policymakers. Industry groups supported an amendment to the Energy and Commerce bill from New Mexico Democratic Rep. Ben Ray Luján that would collect data and require companies to separate transportation costs from clinical costs.

“Getting this wrong could be disastrous for patients who we transport, and it’s just too risky to rush, and it’s too risky to do without good third-party data,” Eastlee said.

Friction from the feds

While several states have passed legislation to protect patients from surprise bills, the responsibility to address air ambulance rides mostly falls to Congress. Federal law largely blocks states from prohibiting surprise medical bills by air ambulance services. The 1978 Airline Deregulation Act preempts state-level economic regulation of air carriers under the Transportation Department, and courts have determined that air ambulances fall into that category.

Some states have tried anyway, but faced hurdles.

A federal judge struck down a North Dakota law banning surprise billing by air ambulance companies and another state law faces a legal challenge before the 8th U.S. Circuit Court of Appeals.

One state that successfully drove change was Michigan, where the Legislature worked with hospitals. Bret Jackson, president of the Economic Alliance of Michigan that lobbied for the legislation, said the law, which required hospitals to first call air ambulance companies in insurance companies’ networks, resulted in more providers joining Blue Cross Blue Shield of Michigan, the state’s predominant insurer.

“If everyone is in network, then you don’t have to worry about surprise bills,” he said.

Wyoming officials are taking a different approach. They plan to request a waiver from the Centers for Medicare and Medicaid Services that would allow Medicaid coverage for patients transported by an air ambulance.

If approved, the state’s Department of Health would entertain bids from air ambulance providers to create a network, and the state would make flat payments to them. Wyoming would recoup the revenue for the program from insurers and individuals already paying for the services.

State insurance commissioners and industry groups have gone head-to-head in trying to convince senators to take their side. “Instead of establishing arbitrary median in-network rates, data from both insurers and providers should be collected and analyzed,” read a September letter from Richard Sherlock, president of the Association of Air Medical Services, and Carter Johnson, spokeswoman for the Save Our Air Medical Resources campaign. “Meaningful and sustainable legislation can only be introduced once the real cost of service is known.”

North Dakota Insurance Commissioner Jon Godfread urged Senate leaders in a July letter to adopt the air ambulance provisions included so far in the HELP Committee bill.

Godfread said that while air ambulance providers would warn that the benchmarking payment mechanism would reduce access for rural patients, the state’s experience suggests differently.

“North Dakota is about as rural as you can get, and I write to tell you from our perspective, the air ambulance companies themselves have dispelled the myth that they will flee from the rural areas if these reasonable regulations are passed by Congress,” he said. “The only real change achieved by our laws was the protection of our consumers from outrageous balance bills.”