Air ambulance teams train to respond to car accidents on remote highways, cardiac arrests, and children who stop breathing. When the call comes, they go because air medical transport exists to reach patients fast even when they are far away. They often make the difference between life and death.
Last year, a crew responded to a pedestrian struck by a vehicle. The patient had suffered a serious traumatic brain injury, and time was of the essence. Brain tissue does not wait.
Medical crews stabilized the patient and flew them to a hospital in 20 minutes. Ground transport would have taken 61 minutes.
No one stopped to ask if the patient had insurance. Air ambulance teams provide the same life-saving care to every patient regardless of insurance status or ability to pay.
After the flight, the air ambulance company, PHI Air Medical, did not bill the patient for the balance of what was owed. It followed the federal No Surprises Act, which became law in 2020. The company submitted the claim to the insurance company. Later, it found out what the insurer thought the rescue was worth: $25.
Not $2,500. Not $250. $25. That's what the insurer decided it was worth to have a critical care flight crew perform an emergency airway procedure, administer medication to relieve pressure on the brain, and reach definitive care. The air ambulance’s intervention allowed the patient to survive.
President Trump and Congress created the No Surprises Act's Independent Dispute Resolution process to act as a neutral arbitrator to resolve payment disputes like this one. In many cases, the insurer makes initial offers so low that providers are forced into arbitration on nearly every claim. This overwhelms the system and drives up costs until some providers give up and accept whatever the insurer offers.
When providers fight in the arbitration process, the arbitrator sides with companies like PHI Air Medical about 85 percent of the time. But a growing number of insurers have refused to pay the finalized award in clear violation of the law.
PHI Air Medical has more than 3,500 unpaid awards totaling more than $43 million. Of that, 1,000 unpaid arbitration awards of over $21 million are from one insurer. These are final, legally binding awards from certified federal arbitrators that the insurer will not pay.
Enforcement of these decisions is a structural problem that threatens patients. Unfortunately, several courts have held that providers cannot directly enforce these arbitration awards in court, concluding that enforcement lies exclusively with federal agencies. The Centers for Medicare and Medicaid Services and the Department of Labor can fine non-compliant plans or take other steps to address the enforcement gap. Until those agencies act, sophisticated insurers have calculated it is cheaper to ignore an award than to pay it.
The result is a law that is not enforced. Left unaddressed, this gap threatens the financial viability of air medical operators especially in rural and underserved communities where companies like PHI Air Medical is often the only service that stands between a patient and death.
The Centers for Medicare and Medicaid Services and the Department of Labor have the authority to take significantly stronger enforcement action against plans that systematically refuse to pay finalized awards. President Trump’s Great Healthcare Plan promised to “Hold Big Insurance Companies Accountable.” This is the right first step to do so.
Air ambulance teams do not think about billing when they make a rescue. They think about whether they arrived in time and provided life-saving care. The insurer thinks about twenty-five dollars. One of us is in this role to help the patient. It should not take an act of Congress to figure out which one.
Captain Ross Gamble is West Region Aviation Manager and Michael Jasumback, MD FACEP, is Medical Director of PHI Air Medical.
