L. had a heart attack at his deer camp in the Northeast Kingdom — a hundred miles from the nearest cardiac-cath lab. EMS made the call to airlift him. He survived. Three months later, the air-ambulance company sent him a bill: $24,000, of which $18,000 was "member responsibility" after his insurer's discount.
Air ambulance is one of the four categories explicitly covered by the federal No Surprises Act (effective January 2022). Under the law, an out-of-network air-ambulance provider cannot bill the patient more than the in-network cost-share for the equivalent service. The provider and insurer settle the remaining amount through the federal Independent Dispute Resolution process — the patient is not a party to that negotiation.
The air-ambulance company had billed L. as though no NSA protection applied. They were essentially gambling that he didn't know.
Audra's audit cited 45 C.F.R. § 149.130 (the air-ambulance specific NSA section) and the published in-network rate L.'s plan would have paid for an equivalent ground-distance air transport. The appeal letter went to the air-ambulance company, his insurer, and CMS's No Surprises Act enforcement portal at the same time — the federal complaint takes about 4 minutes to file and triggers a separate compliance review.
The air-ambulance company reissued the bill 23 days later at $620 (his in-network coinsurance for medical transport). The CMS complaint was closed with a notation that the company had brought the billing into compliance.