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  > discovered the "life hack" of having an extremely inadequate network

The article covers this. Ambulance providers are strongly incentivized not to join insurance provider networks, and as a result more than 80% of ambulance rides in the US are “out of network”. So the inadequacy of the network is probably not the insurer’s fault.

Be that as it may, the law in California forbids the insurance company from refusing to pay at the in-network rate in an emergency. As evidence, I'd submit the claim they immediately paid when called out on this.

If the insurance company weren't cynically exploiting people's lack of knowing their rights, they'd at least send a form letter to the patient saying "Please send us whatever proof from the hospital that you had a legitimate emergency and if approved, we'll pay <insert details> percent." Instead, they pay nothing, shove their fingers in their ears, and let the balance bill come to the patient, and hope nobody tells on them.

The only ambulance rides that should be billed like this are frivolous ones, like if someone is rear-ended at 1MPH, are unharmed, and they lay on the ground and fake an injury and demand to be transported to try to support a fraudulent legal case.

But isn't the California law requiring the insurance company to act as a sin-eater here? They seem to be the only people you were frustrated with, even though they are not the ones who charged you $1000.

They had the duty to pay and they try to trick every one of their customers into not realizing that, so that's why I'm only mad at them.

I acknowledge that the CA law is forcing them to, in the mechanism the article covers, causing them to subsidize other people's care, and this is happening in many areas of healthcare too.

Though those costs are surely accounted for when they set their premiums, which for 2025 amounted to just over $32,000 for my family.

> isn't the California law requiring the insurance company to act as a sin-eater here?

American healthcare providers have done a pretty good job at transferring PR liability to insurers. Cost inflation, in America, is mostly a problem at the provider level.

The insurer is being forced to act as an insurer, by paying the $1000 they're supposed to cover.

Did they know they were supposed to cover it, or did the provider make a billing error? Even if there's no error, why is a government-run ambulance service making this the patient's problem, if the law says that they definitely have to pay? Why did it cost $1000 anyway, is that a reasonable price?

- The "why $1000" part is the subject of the article (I assume COVID-era inflation has brought that up to about $1700 similar to everything else)

> why is a government-run ambulance service making this the patient's problem

Whether government or private, they just want their money, and the insurance companies shrewdly avoid conversations where they might have to actually pay money. Plus, the ambulance guys probably have barely any documentation they could submit to prove that it was a "real" emergency, without which the $1000 would be the correct bill for me.

Insurance company's "genius" here is just remaining quiet and saying nothing, guaranteeing the average person will either get sent to collections by the ambulance, cut a deal with the ambulance, sell their plasma and subsist on ramen to afford it, or charge it on a credit card. And none of those involve the insurance sociopaths at all.

The article really proves that a "network" doesn't even make sense for this particular service. The insane part to me is that the insurance companies are allowed to pretend it does, and that they even have any "network" and impose the in/out of network distinction at all.

It's like if your Internet service came with "unlimited data" but when you read the fine print everything is pay-per-MB besides one single unpopular website.

As an ex-paramedic and EMT, both with County Fire and private, there are absolutely those. But many-a-time, some of the blame falls on the physician. Medicare has, for one example, a lovely little form to fill out, just a few fields, mostly checks and multiple choice, to explain why the need for a "fully equipped BLS (or ALS) ambulance" was required, versus POV (private owned vehicle) or cabulance.

The number of times we'd have to hang out at the charge nurse's desk because the physician had scrawled a signature at the bottom of the form and nothing else, etc., was ... staggering.

If that doesn't give that reasoning (unable to stand steady, fall hazard, need for continuous O2, etc., etc., etc.) then no pay. And many insurers would use that same paperwork, not just Medicare. Could we fill it out ourselves? No. I'm not risking my EMS career to be at the center of a "ambulance company employees charged with medicare fraud" news story.

> or cabulance

I'm sorry, are insurance companies now demanding that people use Ubers to get to the hospital?

... do they reimburse those charges? Because wtf.

Cabulance - "wheelchair transport", often staffed by a EMR (emergency medical responder, a lower level than EMT). Someone who needs assistance and support getting where they're going, but is not in need of or likely to need medical treatment or support during the trip.

And they are reimbursed, or actually generally billed to insurance.

Oh, ok. When I posted that I genuinely thought they wanted people to call Ubers, etc.

This is less terrifying, thank you for clarifying!

I mean in real life, that is EXACTLY what many people do every day.

I had a very similar experience. Except unlike you I wasn't aware of that requirement at the time, and ended up paying all of it. I did complain to the insurance company that the amount I owed didn't seem right, and they told me it was my fault for using an out of network ambulance.

Unreal you have to go through this in the richest country in the world.

Family members have been in ambulances a few dozen times over the decades. There is no concept of a bill or paperwork for it. Like borrowing a book from the library.

Was this Cigna? Same thing happened to me in SF in the same timeframe.

It took 5 times of me calling and explaining that they can’t charge it as out of network before they adjusted it.

Not surprising. They clearly care(d) a LOT about the regulators asking questions. I was actually shocked that this mechanism was surprisingly effective at reining in abuses from insurers.

It could have been Cigna -- I've cycled between probably every possible insurer during my career. Dirtbags, the lot of them.

    > I immediately filed a complaint with the insurance company's California regulator (at the time it was the Dept of Insurance for this one, but it seems most or all now are under the Department of Managed Health Care) since insurance companies are by law obligated to pay at the in-network rate in the case of an emergency (which presumably is why you call an ambulance in the first place). Within 2 weeks I received a letter from the insurance company that all was completely fine and that they'd corrected the situation and paid the bill.

First: Hats off -- nice work.

What annoys me the most about this story: There should be a disportionately large penalty that the insurance must pay to the health care regulator for cases like this. It would discourage this kind of illegal behaviour.

Agree. I would be utterly shocked if this exact same scam didn't play out for every ambulance call in San Francisco (And according to this article, it's actually completely normal that the "networks" are nonexistent, so multiply that by every city and town!)

What percentage of patients are likely to be taking ANY action that leads to insurance paying? Either spending (as someone else shared) 5 phone calls trying to convince them, or knowing what regulator to file a complaint with - those are the only options. All other options involve someone else eating that cost. I bet less than 10% get them to pay, so the fine should start at $10,000 - and escalate if they show no improvement.

Another solution: Each year, require health insurance companies to self-report (via third party auditor) the number of violations. Then they need to refund all illegal collections with penalty and pay a large penalty to the regulator. This kind of shitty illegal behaviour would disappear overnight. After the Global Financial Crisis in 2008/2009, some new laws were passed to regulate trading by investment banks. Many of the rules work this way and they work!

Branded GPL-1s cost $1-1.5K a month in the States without insurance coverage, $25 with coverage. Something's rotten, I doubt big pharma eats the difference, they'll get theirs.