EMERGICON’s Founder and CEO Christopher Turner shares his unique perspective on Surprise Billing and its impact on EMS in this recorded conversation. Following the video, please see our October 2026 update Surprise Billing in Texas: What It Means for EMS directly below the video.
Surprise Billing in Texas: What It Means for EMS
Surprise medical bills have been a source of frustration and confusion for patients for years. But when it comes to surprise billing in Texas, emergency medical services present a particularly complicated situation.
Most people don’t plan to call an ambulance. They don’t compare EMS providers, check network status, or ask for a cost estimate before receiving care. When an emergency happens, the priority is getting help as quickly as possible.
That reality raises an important question: When a patient has health insurance and requires emergency ambulance transportation, how should the cost of that service be shared among the patient, the insurance company, and the EMS provider?
It’s a question EMERGICON Founder and CEO Christopher Turner discussed several years ago in a conversation about surprise billing and EMS. Since that conversation, both federal and Texas laws have changed. However, many of the underlying issues surrounding ambulance reimbursement remain just as relevant today.
What Is Surprise Billing?
At its simplest, surprise billing occurs when a patient receives a medical bill or is left with a financial responsibility they did not reasonably expect.
That surprise can happen for several reasons. A patient may unknowingly receive care from an out-of-network provider, which is the situation most commonly associated with surprise medical billing. But an unexpected bill can also result from how a health plan covers a service, including deductibles, coinsurance, coverage limitations, or an insurer paying less of a claim than the patient anticipated.
Historically, one of the most familiar examples involved hospital care. A patient might carefully choose an in-network hospital and surgeon, only to discover afterward that an anesthesiologist, radiologist, or other provider involved in the procedure was outside the patient’s insurance network.
As Christopher Turner explained in the original EMERGICON discussion, patients understandably assumed the various services associated with their medical care would fall under their health insurance coverage. Instead, they could receive a larger-than-expected bill for one portion of their care.
With EMS, however, the situation can be even more complicated. The surprise may not simply be whether the ambulance provider is in or out of network. It may be discovering how much, or how little, the patient’s health insurance covers for an emergency service they had virtually no opportunity to plan for or choose.
That’s one reason surprise billing involving ground ambulances has required a different conversation.
Why Surprise Billing Is Different for EMS
In most healthcare situations, patients have at least some opportunity to make decisions about where they receive care.
An EMS call usually doesn’t work that way.
A patient experiencing a medical emergency typically doesn’t choose which ambulance responds. There may be no opportunity to determine whether the EMS provider participates in the patient’s insurance network. In some situations, the patient may not even be the person who called 911.
The responding EMS crew nevertheless has a responsibility to provide the appropriate emergency care.
As Christopher pointed out in the EMERGICON conversation above, EMS is largely an unanticipated service. Traditional healthcare concepts such as referrals, preauthorization, and choosing an in-network provider don’t fit neatly into a 911 response.
That’s one reason surprise billing involving ground ambulances has been such a difficult issue for policymakers.
The Original Surprise: Will Insurance Cover the Ambulance?
One of the most interesting points Turner raised in the original discussion was that the “surprise” associated with an ambulance bill isn’t necessarily the amount charged by the EMS agency.
For an insured patient, the bigger surprise can be discovering how much of the ambulance service the insurance company will, or will not, cover.
Patients with commercial insurance may pay substantial premiums month after month with the expectation that their coverage will be there when a serious medical emergency occurs. Yet ambulance reimbursement historically hasn’t always fit neatly into the same network model used elsewhere in healthcare.
This creates an unusual situation.
The patient didn’t plan the emergency. The patient may have had little or no choice in which ambulance responded. The EMS agency still had to maintain trained personnel, vehicles, equipment, medications, communications systems, and around-the-clock readiness to respond.
And someone ultimately has to pay for that system.
How the No Surprises Act Changed Medical Billing
The federal No Surprises Act took effect January 1, 2022. It created significant new protections against certain unexpected out-of-network medical bills.
Among other protections, federal law generally protects insured patients from certain surprise bills involving:
- Emergency room services
- Certain out-of-network services received at in-network healthcare facilities
- Air ambulance services
There is, however, an important exception for EMS agencies and their patients: ground ambulance services generally are not covered by the federal No Surprises Act.
That distinction remains in place today.
The Centers for Medicare & Medicaid Services (CMS) specifically states that ground ambulance services are generally outside the federal surprise-billing protections, although state laws may provide additional protections.
For Texas patients and EMS providers, that’s where state law becomes especially important.
Surprise Billing in Texas and Ground Ambulance Services
Texas has taken additional steps to address ground ambulance billing.
Beginning January 1, 2024, Texas surprise-billing protections were expanded to include emergency medical services and ground ambulance transportation for health plans regulated by the Texas Department of Insurance.
Under current Texas rules, covered patients generally cannot be required to pay more than their applicable deductible, copayment, or coinsurance for protected EMS care and ground ambulance transportation.
The Texas Department of Insurance explains that consumers can often identify a state-regulated plan by looking at their insurance card. Cards with “DOI” or “TDI” indicate coverage regulated by the Texas Department of Insurance. Certain other plans may also participate in Texas’ surprise-billing protections.
That distinction is important because not every health plan is regulated in the same way.
Many employer-sponsored plans are self-funded and governed primarily by federal law. Some self-funded ERISA plans may elect to participate in Texas’ surprise-billing system, but patients shouldn’t assume the same rules apply to every insurance policy simply because they live in Texas.
Texas Protections Continue to Evolve
Texas’ ground ambulance protections have continued to evolve since they first took effect.
Legislation passed in 2025 extended provisions governing payments for certain out-of-network emergency medical services through September 1, 2027. Texas law also establishes a payment framework for covered services provided by non-network EMS providers.
If a political subdivision has submitted its locally established ambulance rate to the Texas Department of Insurance, that rate can be used in determining payment. When an applicable local rate hasn’t been submitted, Texas law provides another method for determining payment.
These provisions address one of the fundamental problems surrounding ambulance reimbursement: protecting patients from unexpected balance bills while also establishing a mechanism for compensating the EMS agency that provided the emergency service.
Why Adequate EMS Reimbursement Still Matters
Protecting patients from unexpected medical bills is important.
So is maintaining a sustainable EMS system.
Those goals don’t have to be mutually exclusive.
An ambulance isn’t simply a vehicle that generates a charge when someone takes a ride to the hospital. EMS agencies must maintain readiness 24 hours a day, seven days a week, regardless of how many calls occur.
That means maintaining ambulances, medical equipment, medications, communications systems, trained paramedics and EMTs, and the infrastructure required to respond immediately when someone calls 911.
As Christopher Turner explained in the original EMERGICON conversation, an individual may use EMS very infrequently. But the system still has to be ready every day.
That readiness costs money.
When policymakers consider surprise billing protections, reimbursement rates, and insurance requirements, the long-term financial health of EMS agencies must therefore remain part of the conversation.
The Patient Isn’t the Only Party in the Conversation
Surprise billing is often framed as a dispute between a healthcare provider and a patient.
For EMS, that’s an incomplete picture.
There are at least three major parties involved:
The patient, who needs emergency care and may have little or no ability to choose the provider.
The EMS agency, which responds to the emergency, provides medical treatment and transportation when necessary, and bears the expense of maintaining continuous readiness.
The health plan, which collects premiums in exchange for providing healthcare coverage and determines how covered ambulance claims are reimbursed.
Turner’s original argument was that meaningful discussions about surprise billing need to include all of these parties.
That remains an important consideration today.
Preventing an unexpected balance bill protects the patient, but the cost of providing EMS doesn’t disappear. A sustainable solution must also provide a reasonable path toward reimbursement for the agency delivering the care.
What Should Texas Patients Know?
The first step is understanding your health insurance coverage before you ever need an ambulance.
Review your health plan documents or contact your insurer and ask how emergency ground ambulance services are covered. Determine whether your plan is regulated by the Texas Department of Insurance and what deductible, copayment, or coinsurance could apply.
If you receive an unexpected ambulance bill, don’t automatically assume the amount is correct, or that you are responsible for the entire balance.
Review the Explanation of Benefits from your insurer and compare it with the ambulance bill. If you believe Texas surprise-billing protections apply to your plan, contact your health plan or the Texas Department of Insurance for assistance.
Patients covered by plans outside Texas’ state-regulated system may have different options, including appealing the insurer’s determination.
What Should Texas EMS Agencies Know?
For EMS agencies, the changing regulatory environment makes accurate and knowledgeable billing more important than ever.
Billing teams need to understand not only how to submit a clean ambulance claim and patient care report, but also which rules apply to different types of insurance coverage, how state reimbursement requirements affect claims, and how to communicate with patients who have questions about their financial responsibility.
That requires staying current with changes in both Texas and federal regulations.
It also reinforces why EMS billing is different from traditional medical billing. The rules surrounding emergency transportation, payer responsibility, network status, Medicare, Medicaid, commercial insurance, and patient balances require specialized knowledge.
Key Takeaways About Surprise Billing in Texas
- Surprise billing occurs when patients receive unexpected charges, often involving out-of-network healthcare services.
- EMS presents a unique challenge because patients generally don’t choose their ambulance provider during an emergency.
- The federal No Surprises Act protects patients from many unexpected out-of-network bills, including qualifying air ambulance bills, but generally does not cover ground ambulance services.
- Texas provides additional protections for emergency ground ambulance services for many state-regulated health plans.
- Not every Texas resident has a state-regulated insurance plan, so the protections that apply can depend on the type of health coverage.
- Protecting patients from unexpected bills is only one part of the issue. EMS agencies must also receive appropriate reimbursement to maintain 24/7 emergency readiness.
- Patients should understand how their health insurance covers ground ambulance services before an emergency occurs whenever possible.
- EMS agencies need billing expertise that keeps pace with changing Texas and federal reimbursement requirements.
Finding the Balance Between Patient Protection and EMS Sustainability
A lot has changed since EMERGICON first discussed surprise billing and EMS.
Texas has established additional protections for many patients receiving emergency ground ambulance services. At the same time, the federal No Surprises Act continues to treat ground ambulances differently from air ambulances and many other emergency healthcare services.
But the central issue raised by Christopher Turner remains relevant.
When someone calls 911, the patient often has little control over the circumstances. The EMS agency still has to respond. And the health insurance system has an important role in determining how that emergency care is funded.
The goal should be a system that protects patients from unreasonable unexpected expenses while providing EMS agencies with sustainable reimbursement for the lifesaving services they provide.
For Texas EMS agencies, navigating those rules is increasingly complex.
EMERGICON specializes in EMS billing services for Texas agencies, combining hands-on claim management with a deep understanding of the state’s evolving reimbursement environment. From payer identification and claims submission to follow-up, compliance, and patient support, our Texas-based team works to help EMS agencies receive the reimbursement they’ve earned while serving their communities with professionalism and compassion.
Learn more about EMERGICON’s EMS billing services and how we help Texas EMS agencies navigate an increasingly complex reimbursement environment.