In an emergency, what will you pay for an ambulance ride?

Here at Philly Health Costs, we see a lot of outrageous bills and get a lot of questions about infuriating insurance practices.

A few weeks ago, I heard from a Bucks County man who'd gotten a $1,633 bill for a seven-mile ambulance ride after passing out in church. The ambulance company, TriHampton Rescue Squad, said he owed the money because the service was not part of his insurance network.

The man didn't want to share his name publicly for fear of being branded a complainer. But we think he is the farthest thing from that, because he raised an important question we had never considered: How could he have gotten an in-network ambulance in an emergency? Does such a thing even exist?

The answer is yes, there is such a thing as in-network ambulances. But in an emergency, there's no way for you to control who comes to pick you up — or whether you wind up with a hefty bill.

Insurance companies negotiate rates with hundreds of providers to offer members discounted rates, which the provider agrees to accept without charging patients anything additional.

Providers that aren't part of an insurer's network are sometimes allowed to "balance bill" patients for whatever their health plan doesn't pay, a practice that results in surprise bills.

Ambulances, especially those that respond in an emergency, are often not part of insurance networks.

Non-emergency ambulances, for patients who are too sick or fragile to be transported by car or taxi to scheduled appointments, often do negotiate rates with insurance companies in exchange for reliable referrals from nursing homes and other providers, said David Albertson, president and CEO of Ambulance Reimbursement Systems Inc. The Allentown-based company handles billing for more than 100 ambulance companies in five states, including TriHampton Rescue Squad.

"On the emergency side, there's absolutely no advantage to that," Albertson said, explaining that ambulance companies can't count on referrals in such cases. Nor do they have any control over which insurer covers the patient.

Many states, including Pennsylvania and New Jersey, have rules that prohibit certain providers, such as emergency room doctors, from balance billing patients, even if they don't have a contract with the individual's insurer.

But those protections don't extend to ambulance bills.

People covered by Medicare or Medicaid should still be protected, but people with private insurance are vulnerable to hefty charges.

That's how our Bucks County reader ended up with a bill he wasn't expecting.

His Cigna insurance plan paid $533 toward the bill, but because the ambulance was out-of-network, the ambulance company was allowed to demand the rest — $1,099 — from the patient.

Cigna tries to negotiate with ambulance providers so that members don't face surprise bills, said Mark Slitt, a spokesperson for the insurer.

"When providers adopt a strategy to remain out of network, they can cause financial distress to our customers and undermine health care affordability," he said in an email.

Independence Blue Cross, the Philadelphia region's largest private insurer, said it has contracts with some ambulance companies to offer in-network rates, which means they won't balance-bill members — but of course, you can't be certain who will fetch you in an emergency.

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Reviewing thousands of medical bills in a nationally representative sample, researchers found that about half of ambulance charges were out of network.

The 2017 study used a national claims database by Truven Health, a market research firm, to analyze bills from patients under 65 with insurance from a large employer.

"When a consumer or patient isn't aware — or can't even possibly be aware — of the network status of their provider, there's a breakdown of information, and that's particularly distressing," said Benjamin Chartock, an associate fellow at the Leonard Davis Institute of Health Economics at the University of Pennsylvania, who co-authored the report before joining Penn.

So what can you do about it?

Once you're in an emergency and have dialed 911, not much.

But take the doomsday planner's approach, and you may be able to lessen the blow.

Find out which ambulance company serves your area, and inquire about their rates, so you know what to expect. Some local ambulance companies offer subscriptions with discounts for frequent riders, Albertson said.

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Already got the bill?

Ask the ambulance company to send an itemized statement, so you can check for any errors that could be adding to the cost.

Check with your insurance company to confirm it paid its share.

Call back the ambulance provider to ask about negotiating the rate in exchange for prompt payment, or to see if they have a financial assistance program.

Your best bet? Don't get in an ambulance unless your health depends on it. Whatever you do, don't decline an ambulance ride if you might be suffering a stroke, a heart attack, or anything else life-threatening. If the expedited ride is responsible for saving your life, you may take a different view of the price.