Service Provider: Air Evac Lifeteam, an air ambulance company that operates 130 bases in 15 states. It’s owned by a holding company that owns four other air ambulance companies and one ground ambulance company. Air Medical, in turn, is owned by the giant private equity firm , or KKR.

Medical Service: Khan was flown from the United Regional Health Care System in Wichita Falls, Texas, to the John Peter Smith Hospital in Fort Worth.

What Gives: Khan got his first call from just three days after the accident, while he was still lying in the hospital. A company representative told him the helicopter ride would likely cost more than $50,000 and asked him how he planned to pay.

For Khan, rapid transportation to the trauma center was absolutely essential since the blood supply to his arm had been cut off, said , the medical director for trauma services at JPS Hospital.

“If there’s no blood going that means there’s no oxygen,” he said. “It there’s no oxygen, that means those cells are going to die.” Minutes are precious and the helicopter can get from Wichita Falls to Fort Worth in an hour or less, half the time it takes by ground ambulance, he said.

But complaints about sky-high bills to patients for air ambulance services are common. Since launching the “Bill of the Month” series in February, NPR and Kaiser Health News have received more than a dozen bills from critically ill patients like Khan who were charged tens of thousands of dollars for an air ambulance ride even after insurers’ payments.

Air ambulance companies defend their charges.

, president of the , a trade group, said air ambulances require a more highly trained crew than a ground ambulance, because only the sickest or most seriously injured patients need air transport.

AAMS to determine the actual cost of a medevac ride. The report found it takes about $2.9 million a year to run a single helicopter base. Each base handles about 300 transports a year, and the rides cost about $11,000 each, according to the report.

A spokeswoman for Air Evac Lifeteam said the company bills people so much because it is trying to make up for what she said are meager payments from Medicare and Medicaid.

“Our real cost per flight is the $10,200 plus the unreimbursed cost on each flight for Medicare, Medicaid and patients without any coverage,” wrote Shelly Schneider, the company spokeswoman.

The Centers for Medicare & Medicaid Services said it pays an average of $4,624 per ride, plus $31.67 a mile — which works out to an average Medicare reimbursement of $6,556 for helicopter ambulance rides for seniors. Medicaid in most states pays less.

The industry has been advocating hard to get Medicare to boost its reimbursements, Sherlock said. in both the House and Senate would do so, but there hasn’t been much movement on those bills.

Others say the industry’s cost estimates are inflated by profit-driven expansion of a lucrative industry. Ground ambulances often carry critically ill patients, too.

Too many air ambulances sit idle much of the time, said , a professor of emergency medicine at the University of Chicago and medical director of the university’s Aeromedical Network.

Blumen said the industry — which is dominated by a few companies owned by private equity firms — expanded dramatically the last time Medicare boosted its payments, in 2002. And now there are — 908 as of last year — fighting for patients and profits at the same time.

“The number of helicopters is outrageous for the continental United States,” he said. In the 1990s, most helicopters ran more than 500 flights per year on average. At that rate, the cost per flight today would be less than $6,000.

A BCBS of Texas spokesman said the insurer does have a contracted rate with an in-network air ambulance company, but it is not Air Evac Lifeteam. After initially refusing to pay anything for an out-of-network claim, it agreed to the $11,972 payment.

But in some sense, the reason ambulance companies charge so much is simply because they can: Air ambulances are largely regulated not as health care but as part of the aviation industry. Federal laws prevent states from limiting aviation rates, routes and services.

So many people have been hit with shockingly high air ambulance bills that members of Congress on both sides of the aisle are trying to do something about it. Legislation to reauthorize funding for the Federal Aviation Administration that is moving through Congress now would set up a council of industry experts to address balance billing and other issues, and set up a complaint line for consumers.

Resolution: Khan has allowed Air Evac Lifeteam to negotiate with BCBS of Texas over the remaining $44,000 air ambulance bill. The company has asked him to appeal to the state’s Department of Insurance, and though he first balked at the suggestion, he’s now considering doing so. Khan says he doesn’t understand why the helicopter flight, an integral part of the emergency medical care he received, is treated differently than his surgeries, nursing care and physical therapy.

“I thought that this was another piece of that puzzle,” he said. “It turns out that this was glaringly different.”

He is waiting for resolution as he gets accustomed to life with his disability. Holding his baby son, he asked in frustration: “How do I hold him while he’s crying and at the same time heat up his bottle?”

Khan, who has had to fight with his insurance company to get coverage for a prosthetic arm, is frustrated to learn that the air ambulance company expects him to pay far more than the actual cost of his flight.

“It’s unfair,” he said. “It’s random, it’s arbitrary. It’s whatever price they want to set. And to put that onto a person who’s already been through what I’ve been through, I hate to say it, but it’s cruel.”

The Takeaway: Most people with health problems serious enough to require a helicopter flight are in no position to ask if the medevac company is in-network or whether there’s a choice. But if you or a family member has time to ask, it could pay off.

Steps you should take if you’re faced with a huge bill for a medevac ride:

• First, let your insurer’s process play out. Blue Cross Blue Shield of Texas first denied Khan’s claim altogether. But he looked closely at his policy and saw that the threat of loss of limb was explicitly covered. He appealed, and that’s when the insurer paid $11,972.
• Second, negotiate! The air ambulance company might be willing to negotiate a settlement for a fraction of the bill to avoid turning to debt collectors, who would pay them pennies on the dollar.

Both Sherlock of the Association of Air Medical Services and Schneider of Air Evac Lifeteam said companies will try to determine what a patient can afford. So people with high incomes may find it hard to obtain a substantial reduction for their bill. Still, if patients know the true cost of the service they received, they may be better equipped to negotiate a discount.

Many air ambulance companies offer membership plans that can cost less than $100 a year, and guarantee that the company will accept whatever payment an insurance company makes without billing the patient for the rest. But buyer, beware: When someone needs an air ambulance, they are often not in a position to choose which company will respond to the call.

Bill of the Month is a crowdsourced investigation byÌýKaiser Health NewsÌý²¹²Ô»åÌý that dissects and explains medical bills. Do you have an interesting medical bill you want to share with us? Tell us about it!

Medical Procedure:ÌýA computed tomography scan, commonly known as a CT or CAT scan, uses X-rays to create cross-sectional images of the body. Hynden got his October scan at Summerlin Imaging Center, a standalone facility in Fort Myers that offers a range of diagnostic tests, including X-rays, MRI and CT scans.

Rick Davis, co-owner of Summerlin, said his center is small and independent, so he doesn’t have much bargaining power. That means insurance companies pretty much dictate what he can charge for a scan. In Hynden’s case that was , including the cost of a radiologist to read the images.

Ultimately, what Medicare decides to pay for a scan sets the standard. “The Medicare fee schedule is what all the other companies use as their guideline,” Davis said. “It’s basically the bible. It’s what everyone goes by.”

Summerlin’s office manager, Kimberly Papiska, said that the maximum the center ever bills for a CT scan is $1,200, but that the rates insurance companies pay are usually less than $300.

Hynden was shocked when he got the second CT scan in January, and the listed price was $8,897 — 33 times what he paid for the first test.

Gulf Coast Medical Center is part of his Cigna insurance plan’s approved network of providers. But even with Cigna’s negotiated discount, Hynden was on the hook for $3,394.49 for the scan. The additional ER costs added another $261.76 to that bill.

What Gives:ÌýWe called Gulf Coast Medical Center and its parent company, Lee Health, to understand why they billed nearly $9,000 for a single test. No one at the health center or hospital would agree to an interview.

Lee Health spokeswoman Mary Briggs responded with an emailed statement: “Generally that it is not unusual for the cost of providing a CT scan in an emergency department to be higher than in an imaging center. Emergency department charges reflect the high cost of maintaining the staffing, medical expertise, equipment, and infrastructure, on a 24/7-basis, necessary for any possible health care need — from a minor injury to a gunshot wound or heart attack to a mass casualty event.”

Do the hospital’s costs and preparations justify a list price that’s so much higher than the nearby imaging center’s tab? We asked some experts in medical billing and management for their thoughts.

Emergency rooms often charge people with insurance a lot of money to make up for the free care they provide to uninsured patients, said Bunny Ellerin, director of the Healthcare and Pharmaceutical Management program at Columbia Business School in New York. “Often those people are what they call in the lingo ‘frequent flyers,'” Ellerin said. “They come back over and over again.”

She said hospitals also try to get as much money as they can out of private insurance companies to offset lower reimbursements from Medicare and Medicaid.

Even in that context, the price of Hynden’s CT scan was off the charts.

Healthcare Bluebook, a health care pricing tool, says with contrast, like Hynden had, in Fort Myers is between $477 and about $3,700. It pegs a fair price at $595.

The higher price from Gulf Coast Medical Center and its parent company could be a result of their enormous pricing power in Fort Myers, said Gerard Anderson, a professor of health policy and management at Johns Hopkins University.

Lee Health owns the four major hospitals in the Fort Myers area, as well as a children’s hospital and a rehabilitation hospital, according to its website. It also owns several physician practices in the area. When you drive around Fort Myers, the blue-green Lee Health logo appears on buildings everywhere.

“Anybody who’s in Fort Myers is going to want to get care at these hospitals. So by having a dominant position, they have great bargaining power,” Anderson said. “So they can raise their rates, and they still do OK.”

Anderson said his research shows hospital consolidation has been driving prices higher and higher in recent years. And because more and more people, like Hynden,Ìý, they’re more likely to be on the hook for huge bills.

So Lee Health and other dominant hospital systems mark up most of their services on their master price lists — the list that prices a CT scan at Lee Health at $8,897. Anderson calls those lists “fairy-tale prices” because almost no one actually pays them.

“Everybody who’s taken a look at it agrees — including the CFO of the organization — that it’s a fairy-tale thing, but it does have relevance,” Anderson said.

The relevance is that insurance companies typically negotiate what they’ll pay at discounted rates from list prices.

So from the master price of $8,897, Cigna negotiated Hynden’s bill down to $5,516.14 — a discount of almost 40 percent. Then Cigna paid $2,864.08, leaving Hynden to pay the rest.

“If it wasn’t for thatÌýCT scan, I don’t think this whole thing would have been so difficult and so blatantly obvious that they’re extremely overcharging for that service,” Hynden said.

Resolution:ÌýHynden never got a definitive diagnosis from the CT scans. Several weeks after his second test, however, he went to a nearby urgent care center, also run by Lee Health, and underwent an ultrasound on his abdomen. That test, which cost about $175,Ìýrevealed some benign cysts that he said his doctor said are likely to go away on their own.

The Takeaway:ÌýTests and services are almost always going to be more expensive in an emergency room or hospital setting. If your doctor suggests you go to an ER, it might be worth asking whether an urgent care or walk-in clinic would suffice.

Sources:ÌýExplanations of Benefits provided by Benjamin Hynden and interviews.

This is a monthly feature from Kaiser Health News and NPR that willÌýdissect and explain realÌýmedical bills in order to shed light on U.S. health care prices and to help patients learn how to be more active in managing costs. Do you have a medical bill that you’d like us to see and scrutinize?ÌýÌýand tell us the story behind it.

Service Provider: Air Evac Lifeteam, an air ambulance company that operates 130 bases in 15 states. It’s owned by a holding company that owns four other air ambulance companies and one ground ambulance company. Air Medical, in turn, is owned by the giant private equity firm , or KKR.

Medical Service: Khan was flown from the United Regional Health Care System in Wichita Falls, Texas, to the John Peter Smith Hospital in Fort Worth.

What Gives: Khan got his first call from just three days after the accident, while he was still lying in the hospital. A company representative told him the helicopter ride would likely cost more than $50,000 and asked him how he planned to pay.

For Khan, rapid transportation to the trauma center was absolutely essential since the blood supply to his arm had been cut off, said , the medical director for trauma services at JPS Hospital.

“If there’s no blood going that means there’s no oxygen,” he said. “It there’s no oxygen, that means those cells are going to die.” Minutes are precious and the helicopter can get from Wichita Falls to Fort Worth in an hour or less, half the time it takes by ground ambulance, he said.

But complaints about sky-high bills to patients for air ambulance services are common. Since launching the “Bill of the Month” series in February, NPR and Kaiser Health News have received more than a dozen bills from critically ill patients like Khan who were charged tens of thousands of dollars for an air ambulance ride even after insurers’ payments.

Air ambulance companies defend their charges.

, president of the , a trade group, said air ambulances require a more highly trained crew than a ground ambulance, because only the sickest or most seriously injured patients need air transport.

AAMS to determine the actual cost of a medevac ride. The report found it takes about $2.9 million a year to run a single helicopter base. Each base handles about 300 transports a year, and the rides cost about $11,000 each, according to the report.

A spokeswoman for Air Evac Lifeteam said the company bills people so much because it is trying to make up for what she said are meager payments from Medicare and Medicaid.

“Our real cost per flight is the $10,200 plus the unreimbursed cost on each flight for Medicare, Medicaid and patients without any coverage,” wrote Shelly Schneider, the company spokeswoman.

The Centers for Medicare & Medicaid Services said it pays an average of $4,624 per ride, plus $31.67 a mile — which works out to an average Medicare reimbursement of $6,556 for helicopter ambulance rides for seniors. Medicaid in most states pays less.

The industry has been advocating hard to get Medicare to boost its reimbursements, Sherlock said. in both the House and Senate would do so, but there hasn’t been much movement on those bills.

Others say the industry’s cost estimates are inflated by profit-driven expansion of a lucrative industry. Ground ambulances often carry critically ill patients, too.

Too many air ambulances sit idle much of the time, said , a professor of emergency medicine at the University of Chicago and medical director of the university’s Aeromedical Network.

Blumen said the industry — which is dominated by a few companies owned by private equity firms — expanded dramatically the last time Medicare boosted its payments, in 2002. And now there are — 908 as of last year — fighting for patients and profits at the same time.

“The number of helicopters is outrageous for the continental United States,” he said. In the 1990s, most helicopters ran more than 500 flights per year on average. At that rate, the cost per flight today would be less than $6,000.

A BCBS of Texas spokesman said the insurer does have a contracted rate with an in-network air ambulance company, but it is not Air Evac Lifeteam. After initially refusing to pay anything for an out-of-network claim, it agreed to the $11,972 payment.

But in some sense, the reason ambulance companies charge so much is simply because they can: Air ambulances are largely regulated not as health care but as part of the aviation industry. Federal laws prevent states from limiting aviation rates, routes and services.

So many people have been hit with shockingly high air ambulance bills that members of Congress on both sides of the aisle are trying to do something about it. Legislation to reauthorize funding for the Federal Aviation Administration that is moving through Congress now would set up a council of industry experts to address balance billing and other issues, and set up a complaint line for consumers.

Resolution: Khan has allowed Air Evac Lifeteam to negotiate with BCBS of Texas over the remaining $44,000 air ambulance bill. The company has asked him to appeal to the state’s Department of Insurance, and though he first balked at the suggestion, he’s now considering doing so. Khan says he doesn’t understand why the helicopter flight, an integral part of the emergency medical care he received, is treated differently than his surgeries, nursing care and physical therapy.

“I thought that this was another piece of that puzzle,” he said. “It turns out that this was glaringly different.”

He is waiting for resolution as he gets accustomed to life with his disability. Holding his baby son, he asked in frustration: “How do I hold him while he’s crying and at the same time heat up his bottle?”

Khan, who has had to fight with his insurance company to get coverage for a prosthetic arm, is frustrated to learn that the air ambulance company expects him to pay far more than the actual cost of his flight.

“It’s unfair,” he said. “It’s random, it’s arbitrary. It’s whatever price they want to set. And to put that onto a person who’s already been through what I’ve been through, I hate to say it, but it’s cruel.”

The Takeaway: Most people with health problems serious enough to require a helicopter flight are in no position to ask if the medevac company is in-network or whether there’s a choice. But if you or a family member has time to ask, it could pay off.

Steps you should take if you’re faced with a huge bill for a medevac ride:

• First, let your insurer’s process play out. Blue Cross Blue Shield of Texas first denied Khan’s claim altogether. But he looked closely at his policy and saw that the threat of loss of limb was explicitly covered. He appealed, and that’s when the insurer paid $11,972.
• Second, negotiate! The air ambulance company might be willing to negotiate a settlement for a fraction of the bill to avoid turning to debt collectors, who would pay them pennies on the dollar.

Both Sherlock of the Association of Air Medical Services and Schneider of Air Evac Lifeteam said companies will try to determine what a patient can afford. So people with high incomes may find it hard to obtain a substantial reduction for their bill. Still, if patients know the true cost of the service they received, they may be better equipped to negotiate a discount.

Many air ambulance companies offer membership plans that can cost less than $100 a year, and guarantee that the company will accept whatever payment an insurance company makes without billing the patient for the rest. But buyer, beware: When someone needs an air ambulance, they are often not in a position to choose which company will respond to the call.

Bill of the Month is a crowdsourced investigation byÌýKaiser Health NewsÌý²¹²Ô»åÌý that dissects and explains medical bills. Do you have an interesting medical bill you want to share with us? Tell us about it!

Medical Procedure:ÌýA computed tomography scan, commonly known as a CT or CAT scan, uses X-rays to create cross-sectional images of the body. Hynden got his October scan at Summerlin Imaging Center, a standalone facility in Fort Myers that offers a range of diagnostic tests, including X-rays, MRI and CT scans.

Rick Davis, co-owner of Summerlin, said his center is small and independent, so he doesn’t have much bargaining power. That means insurance companies pretty much dictate what he can charge for a scan. In Hynden’s case that was , including the cost of a radiologist to read the images.

Ultimately, what Medicare decides to pay for a scan sets the standard. “The Medicare fee schedule is what all the other companies use as their guideline,” Davis said. “It’s basically the bible. It’s what everyone goes by.”

Summerlin’s office manager, Kimberly Papiska, said that the maximum the center ever bills for a CT scan is $1,200, but that the rates insurance companies pay are usually less than $300.

Hynden was shocked when he got the second CT scan in January, and the listed price was $8,897 — 33 times what he paid for the first test.

Gulf Coast Medical Center is part of his Cigna insurance plan’s approved network of providers. But even with Cigna’s negotiated discount, Hynden was on the hook for $3,394.49 for the scan. The additional ER costs added another $261.76 to that bill.

What Gives:ÌýWe called Gulf Coast Medical Center and its parent company, Lee Health, to understand why they billed nearly $9,000 for a single test. No one at the health center or hospital would agree to an interview.

Lee Health spokeswoman Mary Briggs responded with an emailed statement: “Generally that it is not unusual for the cost of providing a CT scan in an emergency department to be higher than in an imaging center. Emergency department charges reflect the high cost of maintaining the staffing, medical expertise, equipment, and infrastructure, on a 24/7-basis, necessary for any possible health care need — from a minor injury to a gunshot wound or heart attack to a mass casualty event.”

Do the hospital’s costs and preparations justify a list price that’s so much higher than the nearby imaging center’s tab? We asked some experts in medical billing and management for their thoughts.

Emergency rooms often charge people with insurance a lot of money to make up for the free care they provide to uninsured patients, said Bunny Ellerin, director of the Healthcare and Pharmaceutical Management program at Columbia Business School in New York. “Often those people are what they call in the lingo ‘frequent flyers,'” Ellerin said. “They come back over and over again.”

She said hospitals also try to get as much money as they can out of private insurance companies to offset lower reimbursements from Medicare and Medicaid.

Even in that context, the price of Hynden’s CT scan was off the charts.

Healthcare Bluebook, a health care pricing tool, says with contrast, like Hynden had, in Fort Myers is between $477 and about $3,700. It pegs a fair price at $595.

The higher price from Gulf Coast Medical Center and its parent company could be a result of their enormous pricing power in Fort Myers, said Gerard Anderson, a professor of health policy and management at Johns Hopkins University.

Lee Health owns the four major hospitals in the Fort Myers area, as well as a children’s hospital and a rehabilitation hospital, according to its website. It also owns several physician practices in the area. When you drive around Fort Myers, the blue-green Lee Health logo appears on buildings everywhere.

“Anybody who’s in Fort Myers is going to want to get care at these hospitals. So by having a dominant position, they have great bargaining power,” Anderson said. “So they can raise their rates, and they still do OK.”

Anderson said his research shows hospital consolidation has been driving prices higher and higher in recent years. And because more and more people, like Hynden,Ìý, they’re more likely to be on the hook for huge bills.

So Lee Health and other dominant hospital systems mark up most of their services on their master price lists — the list that prices a CT scan at Lee Health at $8,897. Anderson calls those lists “fairy-tale prices” because almost no one actually pays them.

“Everybody who’s taken a look at it agrees — including the CFO of the organization — that it’s a fairy-tale thing, but it does have relevance,” Anderson said.

The relevance is that insurance companies typically negotiate what they’ll pay at discounted rates from list prices.

So from the master price of $8,897, Cigna negotiated Hynden’s bill down to $5,516.14 — a discount of almost 40 percent. Then Cigna paid $2,864.08, leaving Hynden to pay the rest.

“If it wasn’t for thatÌýCT scan, I don’t think this whole thing would have been so difficult and so blatantly obvious that they’re extremely overcharging for that service,” Hynden said.

Resolution:ÌýHynden never got a definitive diagnosis from the CT scans. Several weeks after his second test, however, he went to a nearby urgent care center, also run by Lee Health, and underwent an ultrasound on his abdomen. That test, which cost about $175,Ìýrevealed some benign cysts that he said his doctor said are likely to go away on their own.

The Takeaway:ÌýTests and services are almost always going to be more expensive in an emergency room or hospital setting. If your doctor suggests you go to an ER, it might be worth asking whether an urgent care or walk-in clinic would suffice.

Sources:ÌýExplanations of Benefits provided by Benjamin Hynden and interviews.

This is a monthly feature from Kaiser Health News and NPR that willÌýdissect and explain realÌýmedical bills in order to shed light on U.S. health care prices and to help patients learn how to be more active in managing costs. Do you have a medical bill that you’d like us to see and scrutinize?ÌýÌýand tell us the story behind it.