More than a year after their daughter was treated for an eating disorder in Denver, a family is still trying to sort out thousands of dollars in bills from when she had to be taken by ambulance to nearby hospitals.

Ann Sassano, of Chicago, said her daughter was taken by ambulance repeatedly while being treated in Denver last fall, with about eight round trips to three different hospitals for emergencies. Their insurance, Blue Cross and Blue Shield of Illinois, said there were no in-network ambulance providers, meaning the family faced a $15,000 deductible for out-of-network care before the plan would start paying, she said.

Altogether, her daughter received about $20,000 in bills, which would have wiped out her savings, Sassano said. Though their insurance ultimately agreed to pay some of the bills, her daughter is paying about $30 a month to stay out of collections while appealing the remaining ones, she said.

“It’s just a very frustrating situation,” she said.

Blue Cross and Blue Shield of Illinois said it couldn’t comment on individual members’ situations, and that coverage is based on each member’s plan.

“Not all ambulance providers are contracted as in-network providers. Certain ambulance providers may charge amounts in excess of a member’s plan benefits, and this may subject members to a bill from the ambulance provider,” the company’s statement said.

Colorado law offers some protection from surprise bills to people with state-regulated insurance plans, but even they could still receive a larger-than-expected bill if an ambulance provider is a public entity. And of course, that doesn’t help people whose plans are federally regulated, or get their insurance in a different state. The federal No Surprises Act, which limits the circumstances where patients can receive a bill for a larger amount than their insurance covers, doesn’t apply to ground ambulances.

Most ambulance providers haven’t reached agreements with insurance companies on in-network rates, and since they have the option to bill patients for whatever their insurance didn’t cover, it doesn’t create a strong incentive to get into their networks, said Adam Fox, deputy director of the Colorado Consumer Health Initiative.

In fairness, though, there are legitimate concerns as-is about the financial viability of emergency medical response, especially for smaller and publicly owned units, he said.

“If you get in a ground ambulance, the chances are it’s out-of-network,” he said.

An analysis by the nonprofit group FAIR Health earlier this year estimated about 59% of ground ambulance rides taken by people with private insurance were out-of-network in 2022, which was down from previous years. It didn’t specify how large those bills were, though previous studies had estimated averages of less than $500 per bill.

A survey from the Commonwealth Fund found about 10% of working-age adults who reported medical debt said at least some of it came from an ambulance trip. Respondents could report more than one source of debt.

Sassano said the majority of the bills have been taken care of, but she’s still fighting three that total more than $4,000. One was from Denver Health paramedics when Sassano’s daughter was taken to Rose Medical Center, and two were from American Medical Response, for separate trips returning her to the  Eating Recovery Center and taking her to an imaging center so she could get a feeding tube placed in her abdomen.

American Medical Response said that its records showed Blue Cross and Blue Shield of Illinois sent a check to the Sassano family instead of paying the ambulance service directly, which is confusing for patients. Colorado could reduce the odds of that happening by requiring insurance companies to pay ambulance providers correctly, it said in a statement.

“AMR recognizes the complexity of what happens after an emergency illness or injury and has a dedicated team of patient advocates to assist our patients through the transport billing process. If a patient is experiencing a financial hardship, we work with them to find equitable solutions,” the ambulance service’s statement said.

In some cases, their insurance company agreed to cover the trip to an emergency room but not the trip back, or vice versa, Sassano said. In one case, it paid half of the bill for a ride with Denver Health paramedics to University of Colorado Hospital, but didn’t explain why the other half wasn’t covered, she said. Their insurance opted to pay the other half of the bill more than a year after she went in the ambulance.

“There’s no rhyme or reason to it,” she said.

April Valdez Villa, a spokeswoman for Denver Health, confirmed someone had called 911 requesting help for Sassano’s daughter on the dates Sassano named, but said she couldn’t discuss the trips because of privacy concerns. It’s the paramedics’ job to figure out if the patient needs to go to a hospital, but that’s separate from how insurance companies decide what they will and won’t cover, she said.

Sassano said, as far as she can tell, whether a bill is covered may come down to whether someone at the emergency room checked the right box. While not every time her daughter was transported may have been an emergency by their insurance’s definition, she also wasn’t given the option to just call a cab, she said.

“She had absolutely no choice,” she said.

That’s typically the case when patients are transferred between facilities, which means there isn’t much that people can do to avoid significant bills before getting in an ambulance, Fox said. The main option is to go through the insurance company’s process of challenging a bill, or to complain to the Colorado Division of Insurance, he said.

“It’s always important for people to understand they can appeal,” he said.

Sassano said she’s fortunate to be able to assist her daughter with handling the appeals, because it’s taken more than a year, sometimes involving hours on the phone at a time. Not everyone can do that, meaning they may end up stuck with bills they can’t pay, she said.

“You’re at their mercy,” she said. “This is how people go homeless.”

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