Dave Spencer knows the ins and outs of health insurance. He works in provider relations for Anthem, the state’s largest insurance carrier.

But Spencer was still caught off guard and unable to avoid hefty out-of-network bills for a family member’s nonemergency ambulance ride. He ended up spending nearly $4,000 out of pocket on two bills for ambulance transfers from Maine Medical Center to nearby psychiatric hospitals last spring and fall, according to records he provided to the Portland Press Herald/Maine Sunday Telegram.

“Every single part of the insurance process I know in great detail, and I still couldn’t avoid it,” Spencer said. “I just can’t imagine how many people are getting hit with these bills.”

There’s no way to know how many people are getting large bills for out-of-network ambulance service. There are recently passed state laws that – in some cases – can protect patients from receiving such bills. But those won’t help people who, like Spencer, are covered by self-insured plans typically offered by larger employers.

Spencer is now trying to raise awareness about the issue, one of many traps in a complex medical billing system that can surprise and frustrate patients. Spencer and other Anthem officials are lobbying for reforms. While a bill hasn’t yet been introduced, Anthem officials said they intend to work with the Maine Legislature to close loopholes and prevent as many out-of-network bills for nonemergency transportation services as possible.

But any state solution would still not protect all patients at all times because the state cannot regulate self-insured plans the way it regulates plans provided by private insurance carriers.

Self-insured plans are those where an employer collects premiums and takes on the responsibility of paying employees’ and dependents’ medical claims. If a company is not self-insured, it will hire an insurance company to take on the risk of paying claims.

About half of Mainers with private insurance are covered by self-insured plans, which are regulated under federal law.

Advocates say it’s an example of how difficult it is to regulate the industry – and how patients can still be on the hook for thousands in unexpected medical bills.

The two bills Spencer received for ambulance transportation totaled about $5,100, of which insurance only paid for about $1,100 because they were out of network. He did not want to identify the family member who needed the rides to protect their medical privacy.

The 60-year-old from Buxton said he was surprised when he got the first bill in June from an out-of-network ambulance service. So when his family member needed an ambulance transport again in September, he requested Maine Medical Center give him an in-network ambulance provider to limit the cost.

“They just essentially ignored me,” Spencer said.

John Porter, a spokesman for MaineHealth, the parent organization of Maine Med, said the process used by the hospital is to “work through the list and take the first available ambulance provider.” He said the people arranging for ambulance rides can’t be involved in whether the transport is in or out of bnetwork. The primary consideration is to get the patient transferred as quickly as possible, he said.

“It’s in the patient’s best interest to transfer and not linger in the hospital,” Porter said.

One possible legislative response – suggested by Anthem officials – would be to require hospitals and other medical providers to use an in-network ambulance service, when feasible, for the patient.

Justin Van Etten, chairman of Stewart’s Ambulance Service, one of the two ambulance services that provided transportation to Spencer’s family member, said there’s myriad reasons why a patient could end up with a high bill. But one reason is that “insurance companies don’t have adequate EMS networks in their states” resulting in a greater chance patients will receive an out-of-network bill.

Also, Van Etten said, ambulance bills are typically one of the first bills patients receive, and if you have a high-deductible plan, the bill is more likely to be paid from the deductible rather than paid for by the insurance plan. Van Etten said the out-of-network deductible also is typically separate, and much higher, than deductibles for in-network services.

Van Etten said any changes to how ambulances are billed need to be a federal solution, because the state Legislature and Maine Bureau of Insurance are not able to regulate self-insured plans.

“The fixes need to be done at the federal level,” Van Etten said.

Ann Woloson, executive director of Consumers for Affordable Health Care, a Maine-based patient advocacy group, said ground medical transportation was left out of the federal No Surprises Act, which was included in the 2020 COVID-19 relief bill. The No Surprises Act can, in some cases, limit large out-of-network bills to patients, such as when a patient sees an out-of-network doctor at an in-network facility, or for emergency services. But it doesn’t cover all situations.

Woloson said that with limited ability to regulate self-insured plans, it will be difficult for the state to prevent all surprise billing for ambulance transportation.

Van Etten said that if a patient receives a large bill, they should always call their insurance carrier and the ambulance provider, and sometimes the bill can be reduced. He said many people end up paying large bills when they shouldn’t because they don’t question them.

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