If you’re an EMS leader wondering how to keep up with all the changes in reimbursement, you’re not alone.
On March 6, 2025, EMS leaders from across the country joined the International Association of Fire Chiefs (IAFC) and Public Consulting Group (PCG) for a timely and informative webinar: Maximizing Incentives in EMS: Treatment in Place, Alternative Destinations, and Navigating Balance Billing Challenges. The webinar focused on helping EMS agencies make sense of evolving policy guidance and reimbursement challenges
IAFC and PCG addressed some of the tricky questions fire and EMS providers are facing today: How can providers be reimbursed for care that doesn’t involve a hospital trip? And what can be done about the financial uncertainty caused by balance billing?
Federal Guidance: Opening the Door for Expanded EMS Reimbursement
Federal guidance like CMS P22 and SMD 23-006 is giving EMS providers new pathways to reimbursement for services beyond traditional transports. Historically, Medicare only reimburses ambulance providers when a patient is transported to a hospital. This model doesn’t reflect the full range of services EMS professionals deliver in the field.
P22 supports reimbursement for:
- Treatment in Place (TIP): When EMS clinicians treat patients on-scene without transport
- Transports to Alternative Destinations: Such as urgent care clinics or behavioral health facilities
- Triage and Telehealth
While these ideas represent a big step forward, it’s important to note: Medicare still does not reimburse for Treat-No-Transport (TNT). According to the Medicare Benefit Policy Manual, the ambulance benefit is considered a transportation benefit, and without a transport, there is no payable service under Medicare.
Treatment in Place (TIP)
TIP refers to providing medical care at the scene without transporting the patient. It offers a host of benefits:
- For patients: Faster care in a familiar environment, less stress, and greater satisfaction
- For healthcare systems: Fewer unnecessary ER visits and reduced risk of hospital-acquired infections
- For EMS providers: More efficient use of resources and the ability to deliver patient-centered care
TIP also has the potential to lower healthcare costs by avoiding unnecessary ambulance transports and hospital admissions. Despite these benefits, TIP services are not currently reimbursed under Medicare Part B.
What Is Balance Billing?
Balance billing happens when a patient receives a bill for the difference between what their insurance plan pays and what the provider charges. For example, if an EMS provider is out-of-network and the insurer only pays part of the bill, the patient may be left to cover the rest.
To help protect patients, Congress passed the No Surprises Act, which applies to:
- Employer-sponsored health plans, marketplace plans, and individual health markets
- Uninsured or self-pay individuals, who can request a Good Faith Estimate for care
- Emergency air ambulance services, prohibiting balance billing when those services are out-of-network
However, the Act does not currently address Treat-No-Transport (TNT) or Treatment in Place (TIP) which leaves patients vulnerable to surprise bills and EMS providers without reimbursement for non-transport care.
The Gray Area: Treat-No-Transport and Balance Billing
Because TNT isn’t covered under the No Surprises Act, EMS agencies are left in a regulatory and financial gray zone. In response, several states, including Alabama, Tennessee, and New Hampshire, are exploring legislation to support Medicaid reimbursement for TNT. Washington is conducting an actuarial study to assess the financial impact of covering these services.
At the federal level, the Ground Ambulance and Patient Billing Advisory Committee (GASB) is urging that all EMS services—not just transports—be included under No Surprises Act protections. In its August 2024 report, Prevention of Out-Of-Network Ground Ambulance Emergency Service Balance Billing, GASB issued 12 formal recommendations aimed at strengthening patient protections and supporting EMS with fair and consistent reimbursement.
Two recommendations flagged for Congressional action include:
- Expanding federal coverage to include non-emergency services such as TIP and TNT
- Establishing a default national payment standard based on a percentage of Medicare rates for both covered and non-covered EMS services
These proposals signal growing federal recognition that EMS care extends far beyond transport and that reimbursement models must evolve accordingly.
For more information on balance billing and the No Surprises Act, you can visit the Centers for Medicare & Medicaid Services (CMS) page on Ending Surprise Medical Bills or read the Commonwealth Fund’s article on Expanding the No Surprises Act to Protect Consumers from Surprise Ambulance Bills.
GASB’s Call to Action
GASB’s report emphasized that banning balance billing alone is not enough and any solution must reflect the realities of EMS operations. Their recommendations call for a comprehensive approach to protect both patients and providers.
Key highlights from the report include:
Consumer Protections
- Expand coverage to all EMS services, including TIP and TNT
- Set fixed dollar caps on cost-sharing (applied before deductibles)
- Require patient-friendly billing language and greater transparency
- Prevent insurers from shifting costs to patients through increased deductibles or co-pays
Provider Protections and Payment Reforms
- Use a tiered rate-setting process, starting with state or local benchmarks
- Eliminate prior authorization requirements and restrictions
- Guarantee prompt payment directly to EMS providers and encourage better sharing of health information.
- Add guardrails to ensure state-set rates are fair and neither excessive nor punitive to insurers.
State and Local Oversight
GASB affirms that state and local governments should lead in regulating EMS reimbursement and balance billing protections.
Together, these recommendations aim to create a sustainable system that reflects EMS’s unique role in public health and emergency response, even when no transport occurs.
Key Takeaways at a Glance
- P22 & SMD 23-006 create new reimbursement opportunities for EMS services like TIP and alternative destinations
- TIP is a promising, patient-centered model—but lacks standardized reimbursement, especially under Medicare
- Balance billing for TNT remains a gap, with states beginning to take action
- GASB’s recommendations provide a roadmap for fair, practical payment structures
Final Thoughts
The road ahead for EMS includes significant opportunities—and equally significant challenges. As federal and state policies evolve, EMS agencies must stay informed, advocate for fair reimbursement, and embrace innovative care models like TIP.
To learn more about the webinar insights and how PCG can support your agency, reach out or explore more at publicconsultinggroup.com.
