A runner was hit by a car. His ambulance bill was $13,000.

Jagdish Whitten was on a run in July 2023 when a car hit him as he crossed a busy San Francisco street. Whitten, then 25, described doing a “little flip” over the vehicle and landing in the street before getting himself to the curb.

Concerned onlookers called an ambulance. But Whitten instead had friends pick him up and take him to a nearby hospital, the Helen Diller Medical Center, operated by the University of California at San Francisco.

“I knew that ambulances were expensive, and I didn’t think I was going to die,” he said.

Whitten said doctors treated him for a mild concussion, a broken toe and bruises.

As he sat in a hospital bed, attached to an IV and wearing a neck brace, Whitten said, doctors told him that because he had suffered a traumatic injury, they had to send him by ambulance to the city’s only trauma center, Zuckerberg San Francisco General Hospital.

After a short ambulance ride, Whitten said, emergency room doctors checked him out, told him he had already received appropriate treatment and released him.

Then the bill came.

The medical procedure

In emergency medicine, it is standard to transfer patients to centers best equipped to provide care. Ambulances are typically used because they are able to handle trauma patients, with tools to aid in resuscitation, immobilization and life support.

At the first hospital, Whitten said, doctors performed a thorough workup, including a CT scan and X-rays, and advised him to follow up with his primary care physician and an orthopedic doctor. He was evaluated at the second hospital, which specializes in trauma care, and released without additional treatment, he said.

The final bill

$12,872.99 for a six-mile ambulance ride between hospitals: a $11,670.11 base rate, $737.16 for mileage, $314.45 for EKG monitoring and $151.27 for “infection control.”

The billing problem

Ground ambulance services are operated by a hodgepodge of private and public entities – with no uniform structure or regulatory oversight for billing – and most function outside insurance networks. Patients typically do not have a choice of ambulance provider.

There are state and federal laws shielding patients from out-of-network ambulance bills, but none of those applied in Whitten’s case.

Whitten was insured under his father’s employer-sponsored health plan from Anthem Blue Cross. When he received a nearly $13,000 bill months after his short transfer ride, he sent a photo of it to his dad.

Brian Whitten said he was stunned by his son’s ambulance bill from AMR, one of the nation’s largest ambulance providers. Anthem Blue Cross denied the claim, saying the ambulance was out of network and required pre-authorization.

“It didn’t make a whole lot of sense to me because the doctor is the one who put him in the ambulance,” Brian Whitten said.

Kristen Bole, a UCSF spokesperson, said the health system’s standard of care is to stabilize patients and, when appropriate, transfer them to other medical facilities as needed.

Ambulance services operate largely outside of the competitive marketplace, said Patricia Kelmar, senior director of health care campaigns for PIRG, a nonpartisan consumer protection and good-government advocacy organization.

According to a 2023 study of private insurance claims data, about 80% of ground ambulance rides resulted in out-of-network billing.

Generally, out-of-network providers may charge patients for the remainder of their bill after insurance pays. In some cases, patients can be on the hook even when they did not knowingly choose the out-of-network provider. These bills are known as “surprise” bills.

“It’s a financial burden,” said Kelmar, who is a member of the committee created to advise federal lawmakers on surprise bills and emergency ambulance transportation.

Eighteen states have implemented laws regulating surprise ambulance billing. A California law cracking down on surprise ambulance billing took effect Jan. 1, 2024 – months after Whitten’s ambulance ride.

But Kelmar said those state laws don’t help people with employer-sponsored insurance, because those plans are beyond state control.

As of 2022, federal law protects patients from receiving some surprise bills, especially for emergency services. But while lawmakers included protections against air ambulance bills in the law, known as the No Surprises Act, they excluded ground ambulances. Expanding those protections to ground ambulance bills would require Congress to act.

The resolution

Whitten’s father filed an insurance appeal, which Anthem granted. The insurer paid AMR $9,966.60.

Michael Bowman, a spokesperson for Anthem, said AMR had not submitted all the information it required to process the claim, leading to the initial denial. After consulting with AMR, Anthem paid its coverage amount, Bowman said.

But the insurer’s payment still left Whitten with a $2,906.39 bill for his out-of-network ambulance ride. Brian Whitten said he called an AMR customer service number several times to contest the remaining charges but was unable to bypass its automated system.

“I couldn’t find a way to talk to somebody about this bill other than how to pay it, and I didn’t want to pay it,” he said.

Frustrated, Brian Whitten paid the remaining bill in January 2024, he said, concerned it would be sent to a collection agency and hurt his son’s credit.

There was one more twist: He was shocked when he later reviewed his credit card statements and discovered that AMR had quietly but fully refunded his payment in October.

“It’s amazing that he got his money back,” Kelmar said.

In a statement, Suzie Robinson, vice president of revenue cycle management with AMR, said the company’s third-party billing agency regularly performs audits to ensure accuracy. An audit of Jagdish Whitten’s bill “revealed that the care provided did not meet the criteria for critical care,” Robinson said, which prompted the refund.

Robinson said audits indicated fewer than 1% of its 4 million medical encounters annually are billed incorrectly.

The takeaway

Robinson said patients who think AMR has billed them incorrectly should email the company.

For patients who need an ambulance in an emergency, there are few protections – and usually few options: Sometimes you don’t have a better choice than to get in.

Kelmar said she worries not just about the debt those bills create for consumers but also that people may decline vital ambulance transportation in an emergency, for fear of getting hit with an exorbitant bill.

“We just need to bring some sense back to the system,” she said.

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Bill of the Month is a crowdsourced investigation by KFF Health News and The Washington Post that dissects and explains medical bills. Since 2018, this series has helped many patients and readers get their medical bills reduced, and it has been cited in statehouses, at the U.S. Capitol and at the White House.