Air ambulance transports bill out-of-network more than two-thirds of the time, leaving patients with five- and six-figure bills the No Surprises Act does not fully resolve
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More than two-thirds of air ambulance transports are billed as out-of-network, generating some of the highest medical bills patients ever face — often $30,000 to $100,000+ for a single helicopter flight — and while the No Surprises Act (effective January 2022) bans balance billing for these transports, the arbitration system meant to resolve payment disputes has produced awards that exceed Medicare rates by at least 3.7 times. So what? These inflated arbitration awards set de facto price benchmarks that allow air ambulance companies (increasingly owned by private equity firms) to maintain extraordinarily high charge rates, because arbitrators tend to split the difference between insurer and provider claims rather than anchoring to any cost-based standard. So what? Insurers pass these inflated costs through to all plan members via higher premiums — a single air ambulance arbitration award of $100,000+ is spread across thousands of premium-paying members who will never use the service. So what? Patients in rural areas, where air ambulance transport is most commonly needed due to distance from trauma centers, face the highest exposure — and these are the same communities with the lowest incomes and least ability to absorb unexpected medical costs, even with balance billing protections. So what? The No Surprises Act's independent dispute resolution (IDR) process has been overwhelmed, with hundreds of thousands of disputes filed and a massive backlog, meaning the system designed to protect patients is itself failing under volume. This persists structurally because the air ambulance market is highly consolidated (two companies control ~70% of the market), there is no price transparency or competitive bidding for emergency transport, state insurance regulators have limited jurisdiction over air ambulances (which are federally regulated as airlines under the Airline Deregulation Act), and the No Surprises Act deliberately excluded provider rate-setting to secure political passage.
Evidence
GAO report: more than two-thirds of air ambulance transports billed out-of-network. Regulatory Review (July 2025): arbitration awards exceed Medicare rates by 3.7x+ and exceed historical in-network commercial prices by 50%. No Surprises Act (effective Jan 2022) bans balance billing but IDR backlog has created systemic delays. ACEP and CMS fact sheets document the scope of balance billing protections and their gaps. Air ambulance market dominated by two PE-backed companies (Air Methods, Global Medical Response). Airline Deregulation Act preempts state rate regulation of air ambulances.