Author: Matt Zavadsky

Out-of-hospital cardiac arrest (OHCA) remains one of the most time-critical medical emergencies in modern health care. 

Despite decades of research and operational improvements, survival rates continue to vary significantly between communities.

In January 2026, representatives from fire-rescue departments, emergency medical services agencies, and regional health care partners convened as experienced experts in cardiac arrest response. The purpose of the meeting was to examine current challenges and share successful campaigns that have strengthened community response to out-of-hospital cardiac arrest across North Texas.

Participants shared operational insights, data-driven strategies, and community engagement initiatives designed to improve early recognition of cardiac arrest, increase lay responder CPR, expand public access to defibrillation (AEDs), and enhance coordination across the chain of survival.

This white paper synthesizes those discussions into practical recommendations for EMS systems, public safety agencies, health care leaders, and policymakers seeking to strengthen cardiac arrest survival in their communities.

Click here to view and download “EMS with Heart Out-of-Hospital Cardiac Arrest Case Studies from the Southwest Region“.

Here is a well-done news report from South Dakota Public Broadcasting with an excellent framing of essential service designation and patient protection initiatives by Brian Hambek of the South Dakota Ambulance Association.

Interestingly, of the states that have passed statutes designating EMS as an ‘essential service”, only 9 (HI, NC, PA, SC, TN, UT and WV) actually include provisions that require EMS to be funded by local jurisdictions.

Of note in the article, during their testimony opposing patient protection from balance billing legislation, Wellmark Blue Cross Blue Shield made the ‘claim’ that health insurance premiums would increase. However, when asked if they have specific data or an estimate of how much a bill like SB 211 would raise insurance premiums or increase costs for the insured population, Wellmark did not respond.

As EMS stakeholders advocate for essential service designation, the legislation should specifically require that communities assure funding the level of service they desire. Similarly, when insurers claim that premiums will rise, challenge them to a) prove what % of their healthcare expenditures are attributed to EMS, and b) ask them to prove how much premiums will increase if they paid a fair reimbursement for EMS.

Click here for PWW|AG’s summary of state “Essential Service” laws.

Click here for PWW|AG’s summary of state patient protection from ambulance balance billing laws.

—————–

Ambulance services remain in limbo as lawmakers prepare for EMS funding task force

SDPB | By Delainey LaHood-Burns

June 15, 2026

https://www.sdpb.org/healthcare/2026-06-15/ambulance-services-remain-in-limbo-as-lawmakers-prepare-for-ems-funding-task-force

The Emergency Medical Services Funding Task Force is scheduled to meet for the first time in Pierre on Wednesday.

The task force is studying funding models for emergency medical services and the feasibility of making EMS an essential service in South Dakota.

Unlike law enforcement and fire services, EMS is rarely classified as an essential service that must be provided to citizens and is often funded through governmental sources.

The task force was established through Senate Bill 89 this past legislative session. SB 89 was one of several bills introduced during the 2026 session aimed at helping emergency medical services in South Dakota.

Ambulance providers across the state, and the nation, are facing severe workforce and funding issues. Those challenges have forced organizations to shut their doors, including in rural areas like Isabel and Dupree. More urban services have also been impacted, with the Rapid City Fire Department considering ending ambulance coverage to some surrounding areas in 2027 unless funding agreements are reached.

According to Brian Hambek, executive director of the Spearfish Emergency Ambulance Service and president of the South Dakota Ambulance Association, at the center of the EMS funding issue is inadequate insurance reimbursement rates.

For example, Medicare only pays about 55 percent of the cost for a single ambulance run, and Medicare-aged patients make up the majority of calls that Spearfish Emergency Ambulance takes.

“Financing is like a puzzle for EMS,” said Hambek. “You’ve got one section of that puzzle that’s Medicare, another piece that’s Medicaid, another piece is private insurance. And VA and self pays and that type of thing. And it all has to come together to create that picture and how we can operate within that puzzle.”

An aging workforce and decline in new volunteers is also pushing many ambulance services to the verge of shutting down, particularly in rural communities.

The Emergency Medical Services Funding Task Force will hold up to five meetings during the 2026 interim. Its scope includes:

• Examining mechanisms to fund counties and municipalities for the provision of emergency medical services as an essential service.
• Examining policies for ambulance service payments, including reimbursement standards for out-of-network emergency medical services.
• Seeking input from relevant stakeholders on the provision of emergency medical services as an essential service.
• Providing a report with findings and recommendations for legislative proposals to the executive board no later than Nov. 1, 2026.

The task force will also evaluate using Rural Health Transformation Program funds to support emergency medical services.

Funding Task Force Background: A growing focus on the EMS crisis

In recent years, there’s been growing concern in Pierre over the hardships ambulance services are experiencing. During the 2025 legislative session, state representative Eric Emery, a paramedic and program director for the Rosebud Sioux Tribe Ambulance Service, introduced a bill to designate emergency medical services as essential.

The bill required that local governments provide emergency medical services within their jurisdictions, and established an EMS state fund. It ended up failing, but lawmakers passed a resolution supporting efforts to make EMS an essential public service and a 2025 legislative summer study was created.

That interim committee led to more EMS bills being introduced during the 2026 legislative session. In total, legislators considered four bills this year aimed at improving ambulance services in South Dakota: SB 89, SB 211, HB 1023 and HB 1024.

Senate Bill 89: Another attempt at making EMS essential

Senate Bill 89 was introduced by Senator Tim Reed, who co-chaired the 2025 EMS summer study. Originally, the bill worked to make EMS essential by requiring that counties and municipalities provide emergency medical services within their jurisdictions. Additionally, it created the 2026 Emergency Medical Services Funding Task Force.

However, the bill was amended to just encompass creating the funding task force. This is because legislators wanted to better evaluate how to support cities and counties in funding EMS, before mandating that they provide those services.

Hambek said the push in Pierre this year to make property taxes more affordable also played into the decision to gut the bill.

“With the decrease in property taxes going on this year through the legislature, they didn’t want to have to add that on as another taxing regulation for the citizens,” said Hambek. “And I understand that. I get it. But we’ve still got to make that picture fit. We’ve got to make that picture complete. And that’s where Senate Bill 211 would come into play to help paint that picture even better.”

Senate Bill 211: Protecting consumers from surprise ambulance bills

SB 211 aimed at improving private insurance reimbursement rates to ambulance services, while also protecting consumers from surprise medical bills for out-of-network care. The bill failed on the Senate floor this year, but similar policy is likely to be considered in the upcoming task force.

SB 211 required private health benefit plans to reimburse ambulance providers for out-of-network calls at a specified rate. It also prohibited ambulance services from sending patients the portion of the bill that insurers refuse to cover due to being out of network, a practice called balance billing. Balance billing for most emergency services is banned federally by the No Surprises Act, with the exception of ground ambulance services.

As a result, 22 states have now passed laws protecting patients from surprise ambulance bills through legislation like SB 211.

“It’s a patient protection act,” said Hambek. “It means if insurance is going to pay what it costs us to do that call, then we would have no reason to balance bill a patient for anything over. And that protects them. It protects our patients from getting these surprise bills in the mail. So, it’s a win-win on both sides.”

Opponents to SB 211 argued it would raise insurance premiums, as well as remove incentives for in-network participation. For example, they argued in-network providers may go out of network to get higher mandated reimbursement rates.

In response to the argument that SB 211 would raise premium costs, Hambek countered that premiums are rising either way.

“I’ve got private health insurance coverage and they raise my premiums every year. Last year in 2025, they raised them $300 a month. A month. How do people afford this?” said Hambek. “They’re going to raise premiums anyhow. And here’s another side to this. They’ve done the research on this. What private insurance pays, the amount they pay to EMS nationwide is less than 0.2 percent. That’s nothing. That’s a drop in the bucket. Yet they’re fighting tooth and nail to pay us what it costs.”

Wellmark Blue Cross Blue Shield was one of the opponents of SB 211. Wellmark declined to interview for this story, but said in a statement to SDPB that the approach of Senate Bill 211 “raised concerns about how it could affect costs for South Dakotans over time. The bill would have required health plans to pay 275 percent of the Medicare rate for ground ambulance services, without limits on total charges, a dispute resolution process or incentives for providers to participate in insurance networks.”

When asked if they have specific data or an estimate of how much a bill like SB 211 would raise insurance premiums or increase costs for the insured population, Wellmark did not respond.

Hambek said he hopes a similar bill to SB 211 will be introduced in the future, perhaps one that goes further in improving insurance reimbursement rates to ambulances.

“They realize that these insurance companies are not paying their fair share of this,” said Hambek. “But the way that bill was written, one of the lawmakers that helped defeat it is very much an EMS advocate, and she says, ‘Is this bill enough?’ Which means that they’re looking at bigger changes.”

HB 1023 and 1024: Clarifying state statue to help with workforce shortages

Lawmakers successfully passed two EMS bills during the 2026 legislative session to address ambulance staffing shortages. HB 1023 clarifies that registered and licensed practical nurses can serve on ambulance crews. HB 1024 makes it easier for ambulances to recruit and retain ambulance operators.

Both bills came from the 2025 EMS Interim Committee. Hambek said the bills mainly clear up language from when EMS personnel licensing transferred under the Board of Medical and Osteopathic Examiners.

Looking ahead at the funding task force

With no state law requiring EMS be provided as an essential service in South Dakota, there is no safety net for citizens if an ambulance service shuts down.

Hambek believes lawmakers understand that EMS is at a breaking point. He hopes the funding task force comes up with solutions to keep ambulance services open across the state.

“With the essential service, it requires that the cities or counties have a dedicated ambulance service for their communities, for their residents,” said Hambek. “And I asked the legislators, think about this. How many garbage truck drivers or snowplow drivers or police officers are volunteers? Yet, the county has to supply those services. Why should EMS be any less?”

CMS has released a proposed rule that could significantly reshape the future of Ground Emergency Medical Transportation (GEMT) supplemental reimbursement programs nationwide.

For the first time, CMS is proposing provider-specific payment limits for certain targeted Medicaid supplemental payments, specifically identifying GEMT providers, air ambulance providers, and NEMT providers. If finalized as written, the proposal could affect future reimbursement methods, supplemental payment structures, State Plan Amendments, and the long-term sustainability of many Medicaid financing programs.

To help EMS leaders better understand, and respond to the proposal and its potential impact, the PWW Advisory Group team has created a Toolkit featuring educational materials, advocacy tools, and practical guidance. Inside you’ll find:

• Guide to Terms and Concept
• Summary of State GEMT Program Descriptions and Potential CMS Proposed Rule Risk
• The CMS Proposed Rule with Highlights of Language Potentially Impacting GEMT Programs
• Talking Points: Explaining the Potential Local Impact of the CMS Proposed Rule
• Talking Points to Elected Officials: The Potential Local Impact of the CMS Proposed GEMT Rule
• [Editable] Example Agency Letter to CMS on Proposed Rule (with link to send submission)
• [Editable] Example State-National EMS Association Letter to CMS on Proposed Rule (with link to send submission)

The proposal was a major topic of discussion during PWW|AG President Doug Wolfberg‘s Medicare and Reimbursement Update at abc360 conference in Clearwater Beach in June. During his session, Doug noted that if finalized, the rule could limit Medicaid GEMT supplemental payments to Medicare reimbursement levels, potentially creating significant financial implications for some participating public EMS agencies.

The proposal remains open for public comment period, and we encourage EMS leaders to review the rule and consider how it could affect their organizations and communities.

As always, the PWW|AG team will continue analyzing the proposal, developing additional resources, and sharing practical guidance as the rulemaking process moves forward. If you want to find out more about how this will impact your organization directly, or what you should be doing next, get in touch with our experts here.

This action highlights a longstanding problem in ambulance reimbursement: when insurers send payment directly to patients rather than the provider that delivered the care, everyone loses.

While these cases are relatively uncommon, they underscore why 𝐝𝐢𝐫𝐞𝐜𝐭 𝐩𝐚𝐲𝐦𝐞𝐧𝐭 𝐥𝐞𝐠𝐢𝐬𝐥𝐚𝐭𝐢𝐨𝐧, 𝐥𝐢𝐤𝐞 𝐭𝐡𝐞 𝐨𝐧𝐞 𝐢𝐧 𝐏𝐀 𝐫𝐞𝐟𝐞𝐫𝐞𝐧𝐜𝐞𝐝 𝐢𝐧 𝐭𝐡𝐞 𝐧𝐞𝐰𝐬 𝐫𝐞𝐩𝐨𝐫𝐭, 𝐢𝐬 𝐬𝐨 𝐢𝐦𝐩𝐨𝐫𝐭𝐚𝐧𝐭. Requiring insurers to pay ambulance providers directly ensures that reimbursement reaches the organization that incurred the cost of readiness, staffing, vehicles, and patient care.

It also protects patients from inadvertently becoming entangled in billing disputes, collection actions, or even criminal allegations when insurance checks are misused or misunderstood.

Direct payment laws create a simpler, more transparent process that supports the financial sustainability of EMS agencies while reducing confusion and stress for the very patients these systems are designed to serve.

PWW Advisory Group 𝐡𝐚𝐬 𝐝𝐞𝐯𝐞𝐥𝐨𝐩𝐞𝐝 𝐚 𝐬𝐮𝐦𝐦𝐚𝐫𝐲 𝐰𝐢𝐭𝐡 𝐬𝐨𝐮𝐫𝐜𝐞 𝐝𝐨𝐜𝐮𝐦𝐞𝐧𝐭𝐬 𝐨𝐟 𝐬𝐭𝐚𝐭𝐞 𝐥𝐚𝐰𝐬 𝐚𝐝𝐝𝐫𝐞𝐬𝐬𝐢𝐧𝐠 𝐏𝐚𝐭𝐢𝐞𝐧𝐭 𝐏𝐫𝐨𝐭𝐞𝐜𝐭𝐢𝐨𝐧/𝐁𝐚𝐥𝐚𝐧𝐜𝐞 𝐁𝐢𝐥𝐥𝐢𝐧𝐠, 𝐦𝐚𝐧𝐲 𝐨𝐟 𝐰𝐡𝐢𝐜𝐡 𝐢𝐧𝐜𝐥𝐮𝐝𝐞 𝐝𝐢𝐫𝐞𝐜𝐭 𝐩𝐚𝐲 𝐩𝐫𝐨𝐯𝐢𝐬𝐢𝐨𝐧𝐬. 𝐂𝐥𝐢𝐜𝐤 𝐡𝐞𝐫𝐞 𝐭𝐨 𝐯𝐢𝐞𝐰 𝐚𝐧𝐝 𝐝𝐨𝐰𝐧𝐥𝐨𝐚𝐝 𝐭𝐡𝐞 𝐬𝐮𝐦𝐦𝐚𝐫𝐲: https://www.pwwag.com/resources/summary-state-patient-protection-balance-billing-laws

Shaler couple faces new charges over $30K in unpaid ambulance bills

Shaler Hampton EMS took Stacie Hodge to various hospitals 23 times in about one year, director says

By Brian C. Rittmeyer

June 8, 2026

Shaler couple faces new charges over $30K in unpaid ambulance bills

A Shaler couple facing criminal charges for not paying ambulance bills from Ross/West View EMS also owes more than $30,000 to Shaler Hampton EMS, according to additional charges filed against them.

Shaler Hampton EMS Director Eric Schmidt said it is reflective of a bigger issue that cost his agency just over $150,000 in 2025 — and one that proposed state legislation is intended to fix.

Shaler police filed charges June 4 against Wallace Hodge, 57, and Stacie Hodge, 43, the day after Ross police charged the couple.

Ross police allege the Hodges received nearly $8,000 from their insurer, Highmark, to pay Ross/West View EMS for six ambulance trips to hospitals, five from March to December 2025 and one in January, but did not pay those bills.

According to a criminal complaint, Schmidt told Shaler police that Stacie Hodge had been taken to various hospitals 23 times between Feb. 18, 2025, and Feb. 7, 2026, and had not paid for those services.

Shaler Hampton EMS billed Stacie Hodge’s insurer, Highmark. But because Shaler Hampton EMS does not have a contract with Highmark, the checks from Highmark were issued to Stacie Hodge with a message stating the EMS service is out of network and to forward the check to them, the complaint states.

Stacie Hodge did not forward the money to Shaler Hampton EMS, according to the complaint.

A search warrant for the couple’s checking accounts found that the Highmark checks to Stacie Hodge were endorsed by each of them and deposited into Wallace Hodge’s accounts.

According to the complaint, Shaler Hampton EMS billed Stacie Hodge $33,791.20. She had made payments totaling $2,193.44, leaving $30,710 owed.

In the complaint, Shaler police said they spoke with Wallace Hodge on Feb. 16. He said his wife was recovering from surgery at Allegheny General Hospital and participating in a study for ongoing seizures.

While police told Wallace Hodge they wanted to speak with his wife, neither of them have since contacted police, the complaint states.

According to the complaint, the Hodges told Schmidt that they used the money from Highmark for bills and other purchases. Stacie Hodge commented about having an expensive car payment and home expenses.

Part of a bigger issue, director says

While Schmidt told TribLive that the alleged case of the Hodges is “extreme,” it is only part of a problem.

In 2025, 105 out of 233 patients with Highmark insurance, about 45%, kept the money they were given to pay Shaler Hampton EMS, accounting for $150,000 of the $333,740 charged.

Conversely, out of 250 patients with UPMC insurance, only three did not pay, totaling just over $4,000 out of just over $336,000 charged, according to data provided by Schmidt.

The difference is that UPMC sends payments directly to Shaler Hampton EMS, Schmidt said. Because his agency is not under contract with Highmark, it sends payments to patients.

“Highmark is the only company that does that in this market,” he said.

Schmidt said Shaler Hampton EMS, and all EMS agencies in Allegheny County, are not under contract with Highmark because they would then be reimbursed less than providing the service costs.

The money that Shaler Hampton EMS is owed could be used to buy lifesaving equipment and deal with the rising costs of fuel, Schmidt said.

Highmark spokesman Aaron Billger said the insurer does not make direct payment to out-of-network providers, including EMS agencies.

“Our first priority is to our members and clients,” he said. “Providing direct payment without contractual protections and without a tie to the amount of payment is simply not in the best interest of our members.”

Legislation proposed in the state General Assembly, and a concurring bill in the Senate, would mandate direct payment to EMS providers.

Senate Bill 1342, whose sponsors include state Sen. Devlin Robinson, R-Bridgeville, is a companion measure to House Bill 1152, whose backers include state Reps. Jill Cooper, R-Murrysville, and Arvind Venkat, D-McCandless.

They would require insurers to provide “fair and direct” reimbursement for mandated 911 emergency medical services regardless of whether the EMS provider is in network.

“Our EMS providers are facing an ongoing financial crisis while continuing to answer every emergency call, every hour of every day,” Robinson said. “These professionals do not have the option to decline service based on reimbursement rates or insurance status. This legislation recognizes the essential nature of emergency medical services and helps provide the financial stability needed to keep ambulances on the road and providers serving our communities.”

Cooper says her measure has strong bipartisan support, with 68 cosponsors.

”My legislation puts a circle around 911 calls because that is what every municipality and ambulance in the state is required by law to make that call. They can’t say, ‘Oh, no, we’re not coming,’ ” she said. “The reason for this bill is to help sustain our ambulance services so they can receive the payment directly from the insurance company so they’re not spending time chasing payments.”

The Hodges do not have attorneys listed in court records.

Shaler police charged Wallace Hodge with felony counts of theft of services, theft by failure to make required disposition of funds received and conspiracy. Stacie Hodge also is charged with felony counts of theft by failure to make required disposition of funds received and conspiracy, and a misdemeanor count of theft of services, according to court records.

Ross police charged each of them with felony counts of theft by failure to make required disposition of funds and criminal conspiracy, and a misdemeanor count of theft of services.

They were arraigned June 5 on both sets of charges and released on nonmonetary bonds, according to court records.

Their preliminary hearings on the Ross charges are scheduled for June 24 before District Judge Richard G. Opiela. For the Shaler charges, their preliminary hearings are set for June 25 before District Judge Daniel J. Konieczka Jr.

The AIMHI Fleet Management Committee held a special session on becoming a Ford Warranty Repair Shop. Becoming an authorized Ford Motor Company warranty repair facility can provide several strategic, operational, and financial advantages for an ambulance agency, especially agencies operating large fleets of Ford-based ambulances such as Transit, F-Series, or E-Series chassis.

Programs are typically administered through Ford Pro and the Ford Fleet Service Program.

In this meeting, Fleet Manager Kenneth Ekenseair of Metropolitan Emergency Medical Services (a.k.a. the Little Rock Ambulance Authority) discussed the benefits of MEMS becoming a Ford Warranty Repair shop, and the road to attaining this designation.

Click here to view a summary of the benefits of becoming an authorized Ford Motor Company warranty repair facility.

Click here to access a summary of the process for obtaining this designation.

Click here to watch a video of the meeting.

The Centers for Medicare and Medicaid Services has issued a proposed rule that could have major long-term implications for Ground Emergency Medical Transportation (GEMT) reimbursement programs nationwide.

For the first time, CMS is proposing a formal provider-specific payment limit on certain targeted Medicaid supplemental payments made to transportation providers, specifically identifying GEMT providers, air ambulance providers, and NEMT providers within the rule language.

Under the proposal, targeted Medicaid supplemental payments for GEMT providers would be limited to the equivalent Medicare Ambulance Fee Schedule (AFS) payment rates for comparable services.

CMS specifically states that Medicaid supplemental payments tied to GEMT arrangements could not exceed the applicable Medicare AFS payment amounts, including the associated base rates, mileage, geographic adjustments, and rural/super-rural add-on calculations.

This proposal represents a potentially significant policy shift because many current GEMT supplemental payment methodologies nationally are based on cost reconciliation models or Average Commercial Rate (ACR)-style calculations that can exceed traditional Medicare ambulance reimbursement levels.

CMS specifically noted concerns that some targeted supplemental payment arrangements are financed through intergovernmental transfers (IGTs) and “provider-funded mechanisms” (Provider Tax) that, in CMS’ view, may reward providers based more on their ability to finance the non-federal share than on improving Medicaid access or quality outcomes.

CMS also specifically identifies GEMT supplemental payments among the targeted practitioner/provider payment arrangements it believes require additional fiscal oversight and Medicare-based payment limits moving forward.

If finalized as written, this rule could substantially alter future GEMT financing structures, supplemental payment ceilings, SPA methodologies, and the long-term sustainability of Medicaid supplemental reimbursement programs for ambulance agencies across the country.

The payment limits would be effective with the first rating period beginning on or after January 1, 2029.

PWW Advisory Group is actively reviewing the proposed rule and will continue providing updates and strategic analysis to the EMS industry as additional guidance emerges.

Click here to see a highlighted version of the proposed rule identifying the ambulance provisions.

Click here for the release from CMS.

This is a very well-done news report, with logical options articulated by the Rapid City Fire Chief.
 
The issues in South Dakota highlight the plight of agencies trying to provide the service levels desired by the community, in the face of rising costs and stagnant fee-for-service reimbursement; especially in the absence of state legislation for essential service designation, Medicare and Medicaid reimbursement levels, and effective patient protection from balance billing legislation that requires state regulated health plans to provide adequate reimbursement for ambulance service.

An analysis of the average charges and reimbursements for ambulance agencies in South Dakota derived from the PWW|AG Q1 2026 EMS Financial Index reveals the following:

Rapid City (SD) FD may need to reduce ambulance coverage area without funding solutions
SDPB | By Delainey LaHood-Burns
Published May 4, 2026
———————–  
https://www.sdpb.org/healthcare/2026-05-04/rcfd-may-need-to-reduce-ambulance-coverage-area-without-funding-solutions
 
Emergency medical service providers across the nation say they are on the brink of collapse, and many ambulance providers in South Dakota are struggling to keep their doors open. While rural services have been hit hard, even the state’s urban EMS organizations are facing difficult choices.
 
Currently, the Rapid City Fire Department is fighting to maintain its coverage of areas outside of city limits. Since its inception in 2003, the department has served a roughly 3,200 square mile area, including Rapid City, Box Elder, New Underwood, Summerset and portions of Pennington, Custer and Meade County.
 
In December 2025, Rapid City Fire Chief Jason Culberson sent letters to the city’s neighboring jurisdictions indicating that the ambulance service can no longer sustainably cover areas outside city limits without funding support. An example of one of these letters, sent to the Meade County Commission, can be found online.
 
According to Culberson, this comes as the costs to operate an ambulance service have skyrocketed, while insurance reimbursement rates are stagnating. Additionally, Rapid City and the surrounding communities are growing substantially, leading to increased call volumes. According to population estimates, Rapid City has grown by nearly 12,000 people since 2020.
 
“We’ve stretched our folks to the max. We’ve asked them more and more and more all along,” said Culberson. “In 2010, we were doing about 10,000 to 12,000 calls, and now we’re doing 22,000 calls.”
Culberson said the department handled 2,655 medical calls outside of Rapid City last year. In order to continue the level of coverage they’ve operated at, more units and staff are needed.
 
The Rapid City Fire Department’s ambulance service is an enterprise fund, with the vast majority of its revenue generated through the transportation of patients. However, reimbursement rates for those patient transports are significantly less than the actual cost of an ambulance run.
 
“Ultimately, the insurance providers are determining what it cost to provide the service,” Culberson explained in a Meade County Commission meeting in March. For example, the base rate of a Basic Life Support call outside of Rapid City limits costs $1,080. In contrast, Culberson said Medicaid only reimburses $255.71 for that same call.
 
About 72 percent of the Rapid City Fire Department’s ambulance payer mix comes from government health insurance programs, including Medicare, Medicaid, Veterans Affairs and Indian Health Services.
 
Over the last five years, Culberson said reimbursement rates for those payers have generally plateaued.
 
“So you see this leveling off of reimbursement, the costs that have shot up since 2020,” said Culberson. “We used to be able to buy an ambulance for about $150,000, and now they are $250,000 to $300,000.
So those two have just diverged from each other. We’re at a point that we need to ask for help.”
 
In his letter, Culberson stated that the Rapid City Fire Department will need to stop its ambulance response coverage to some of its surrounding jurisdictions if formal funding agreements aren’t reached by the end of December 2026. However, he said the department will do everything it can to not leave people without ambulance services in an emergency.
 
“I want to be clear that as long as progress is being made going forward, that we’re not going to stop just because there isn’t a contract totally inked and penned,” said Culberson.

“We’ve gone down this path before it got to this point where it’s an emergency, where we were trying to work on it and nothing ever happened,” he continued. “It just stagnated, stalled and stopped. So that’s why I put a deadline on it. My whole goal is to move forward. But I also want to be clear, if no progress is getting moved forward, we may have to make the hard decision not to respond to those areas.”
 
According to Culberson, he’s had positive conversations with the surrounding communities that could lose their coverage. He says those areas have several options in terms of funding, including setting up contractual service agreements, forming ambulance taxing districts or trying to get coverage from other ambulance providers outside of the Rapid City Fire Department.
 
“The county could just put it in their line item as a budget line item and be able to fund it, which I think is an option – a very easy one,” said Culberson. “Another option is the tax district route, which not always is popular for obvious reasons. When you’re starting to talk about adding onto our property taxes, which are already high. So those are really the two main options. Or the last option is that the areas [decide] they don’t want to have ambulance services, period. I don’t like that option. I don’t think it’s a great option, especially if I lived in that area.”
 
In South Dakota, there’s no statutory requirement for counties or cities to provide ambulance services to their residents. Therefore, if an existing ambulance provider closes or must reduce its coverage area, impacted communities can be left with no ambulance service in an emergency.
 
State lawmakers are working to address this issue with the Emergency Medical Services Funding Task Force, which meets this summer. The task force will study funding mechanisms to support EMS as an essential service, similar to fire and law enforcement.
 
“My hope is they find a realistic funding source to get a baseline of EMS throughout the state of South Dakota,” said Culberson. “Relying on volunteers and other municipalities just to cover the entire state on hopes that they will continue to provide services, those days are done.”
 
While the issue with Rapid City Fire Department’s ambulance service affects multiple counties and municipalities, Culberson believes there are simple and achievable solutions that will ensure citizens have continued coverage. He also said those solutions don’t need to be costly, especially if each area can contribute its portion so the RCFD can continue the broader level of service it’s provided for decades.
 
Currently, the Rapid City Fire Department has several small contracts with entities like Summerset and Conata Basin to provide coverage.
 
Although he feels positive about the progress made so far, Culberson says it’s been hard to face the breaking point that EMS has reached.
 
“This one’s a big one for me,” said Culberson. “The first half of my leadership career was EMS, and this was always something I worked on. Try to make it sustainable and make it appropriate and make sure everybody was cared for. And so when we get to this point where we’re having to ask for funding in order to just provide a basic level of service, that’s a tough spot.”

Interesting editorial and perspective from an EMS clinician in a well-respected healthcare publication.
 
State balance billing laws have been all over the map (literally and figuratively) and only apply to state-regulated plans.
 
The EMS profession should be paying closer attention to the continued call for federal action on surprise payments, and the status of the GAPB committee recommendations to Congress.
 
We should be advocating for our patients by encouraging Congress to adopt the GAPB committee recommendations, which can be found here: https://www.cms.gov/files/document/report-advisory-committee-ground-ambulance-and-patient-billing.pdf

Your Patients Are Getting Surprise Ambulance Bills. Federal Law Still Allows It.

— Excluding ground ambulances from the No Surprises Act has clinical consequences

by Emily James

April 19, 2026 

https://www.medpagetoday.com/opinion/second-opinions/120845

Your patient called 911. They had no say in which ambulance responded. The dispatcher chose, the system routed them, and a crew arrived. Care was delivered. Transport was completed, and weeks later, a bill arrived for $900, $1,500, $2,400, or some other absurd amount. Sure, their insurance covered part of it, but the rest landed on them. And under current federal law, every part of that scenario was entirely legal.

The No Surprises Act, which took effect in January 2022, was a landmark patient protection measure that eliminated surprise billing across most emergency and out-of-network settings. It covered air ambulances. It covered out-of-network emergency physicians, anesthesiologists, and radiologists. It explicitly did not cover ground ambulances, which are the most common form of emergency medical transport, leaving an estimated 1.5 million privately insured patients exposed to surprise bills each year.

As a paramedic who has worked within private emergency medical services (EMS) for nearly a decade, I have watched this gap widen in real time. Patients are stabilized and transported, and then they’re left to navigate a billing system that they don’t understand and that federal law has declined to regulate. This is a gap with direct clinical consequences that emergency and acute care providers should understand.

The Numbers

Approximately 85% of emergency ground ambulance rides are out-of-network. A 2020 Health Affairs analysis found that roughly half of emergency ground ambulance rides resulted in an out-of-network charge for privately insured patients, with a median surprise bill of $450. High-end cases routinely reach into the thousands.

The clinical consequence that tends to receive the least attention is that some patients are delaying or forgoing 911 calls because they fear the bill. This is not a hypothetical. It is a documented pattern of care avoidance driven by financial calculation rather than medical judgment, and it means that some of the patients not arriving in the emergency department are making that decision at home, alone, weighing the cost of the ambulance against the severity of their symptoms.

That calculation will not always go the right way.

Why the Gap Exists and Persists

The exclusion of ground ambulances from the No Surprises Act was deliberate. Congress cited the complexity of ambulance regulation, referring to the mix of private companies, municipal fire departments, hospital-based services, and volunteer squads, as a reason to defer action. The American Ambulance Association lobbied successfully for the carve-out, arguing that the No Surprises Act’s arbitration framework would be unworkable for ambulance providers. In its place, Congress created the Advisory Committee on Ground Ambulance and Patient Billing (GAPB committee) to study the issue and return with its recommendations.

The committee delivered its report in August 2024. Its recommendations were specific and actionable: prohibit balance billing for out-of-network ground ambulance services; cap patient cost-sharing at the lesser of $100 or 10% of the bill; require insurers to process payments within 30 days; and mandate billing transparency. On reimbursement rates, the committee recommended deferring to state and locally set rates with federal guardrails, which is a framework designed to protect rural and smaller agencies from rate compression while still shielding patients.

Congress has not acted on those recommendations.

Why State Solutions Aren’t Enough

Twenty-two states have enacted some form of ground ambulance billing protection. It sounds like meaningful progress, and in some cases it is. But state laws cannot reach self-funded employer-sponsored health plans, which are governed by the Employee Retirement Income Security Act of 1974 (ERISA) and explicitly preempted from state regulation. Approximately 63% of workers with employer-sponsored insurance are in self-funded plans. That means the majority of working Americans with job-based coverage remain unprotected regardless of what their state has done. A patient in a state with strong ambulance billing laws may still receive a surprise bill if their employer uses a self-funded plan, which is something that the largest employers almost uniformly do.

This is not a gap that more state legislation can close. It requires federal action.

What the Clinical Community Can Do

Physicians and other acute care providers are positioned to move this issue in ways that EMS providers alone cannot. Emergency medicine, hospital medicine, and primary care organizations carry legislative influence that individual paramedics do not. When professional societies weigh in on patient safety issues — and care avoidance driven by billing fear is a patient safety issue — Congress listens differently than when it hears only from industry stakeholders and patient advocates.

The GAPB committee has done the analytical work. The report is on Congress’s desk. What has been missing is urgency from the clinical community. This refers to the providers who see the patients who waited too long, or the family members who explain that their loved one didn’t call because they were worried about the bill.

Every month without federal action is another cycle of patients absorbing costs they had no power to prevent, for a service they had no power to choose. The No Surprises Act was a genuine achievement with one significant exception baked into it.

That exception was always meant to be temporary.

It has not been.

Related:

Expanding the No Surprises Act to Protect Consumers from Surprise Ambulance Bills: Map of State Laws

February 5, 2026https://www.commonwealthfund.org/publications/maps-and-interactives/expanding-no-surprises-act-protect-consumers-surprise-ambulance

Ambulance theft is no longer a rare or isolated event—it is a predictable and growing operational risk.  Industry data suggests that an ambulance is stolen approximately every two weeks in the United States, most often from hospital ambulance bays, but increasingly from active scenes. What was once considered an anomaly is now presenting serious and escalating consequences—including police pursuits, spike strip deployments, vehicle crashes, and situations where patients and crews are placed in harm’s way.

The uncomfortable truth is this: many of these incidents are preventable.  This timely and practical webinar brings together operational leadership, regulatory insight, and legal expertise to examine ambulance security from every angle—what’s happening, why it matters, and what you can do about it now.  The Academy of International Mobile Healthcare Integration (AIMHI), Pro EMS and Page Wolfberg & Wirth Advisory Group (PWWAG) are teaming up to help you address this issue.

When:  Tuesday, April 28, 2026, 12n ET

Panel

Rob Lawrence – Pro EMS/AIMHI
President of the Academy of International Mobile Healthcare Integration (AIMHI) and Executive Director of the California Ambulance Association, bringing national perspective and frontline insight into EMS operations and risk.

Bill Mergendahl, Pro EMS
President of ProEMS, offering real-world operational experience on balancing rapid response with vehicle and crew security.

Mark Postma, SVP, Government Relations, Patient Care EMS Solutions
Experienced EMS leader offering insight into standards, compliance expectations, and the evolving role of vehicle security in modern EMS systems.

Doug Wolfberg, Esq. – PWWAG
Nationally-recognized EMS attorney with Page, Wolfberg & Wirth, providing clarity on liability, foreseeability, and the legal consequences of preventable ambulance theft.

Matt Zavadsky – PWWAG, Moderator
A nationally recognized EMS leader and strategist, guiding the discussion and drawing out practical insights across operations, regulation, and law.

Register Here: https://prodigyems.zoom.us/webinar/register/5417760399888/WN_kWrSTW3GTQWoYZRUKUlH6g