This story is part of a partnership that includes WBUR, NPR and Kaiser Health News. This story can be republished for free ( details ).

Kristina Cunningham was in stable condition on an evening in June, when EMTs lifted her gurney into a medical flight, bound for Boston.

The 34-year-old couldn’t use her right arm or speak clearly after a stroke six days earlier, and still had two blood clots at the base of her brain. Cunningham’s dad, Jim Royer, remembers doctors at the small hospital in Wichita, Kan., where Cunningham had attended a family wedding, saying she needed to see a neurosurgeon.

“There was discussion of flying her to St. Louis, there was discussion of flying her to Chicago, there was discussion of flying her to Dallas,” Royer recalled, but “we don’t have family in any of those locations.”

So the doctors arranged to transfer Cunningham, via an Angel MedFlight Learjet, to Massachusetts General Hospital, where she would be diagnosed with a rare blood vessel disease of the brain. MGH is about an hour from Cunningham’s home in Berlin, Mass. — and her 7-year-old son. Cunningham’s doctors and her insurer, CareFirst BlueCross BlueShield, based in Maryland, agreed the transfer was medically necessary.

“We assumed it would be [covered],” Royer said, “because it was supposedly preapproved by the insurer before any flight took place.”

Royer said he and Cunningham didn’t think about the Angel MedFlight piece of her health scare again until a letter arrived in August. It was a one-page “explanation of benefits” with a jaw-dropping total in a column labeled “other amounts not covered.”

“When I got the bill for $474,725, I’m thinking six or seven flights, and you can buy a whole new jet,” Royer said with a wry laugh.

That nearly half-million dollars is the total of four items, the largest of which is a per-mile charge. That figure, $389,125, breaks down to $275 a mile.

“It’s larger than any surprise medical bill I’ve personally seen,” said Chuck Bell, program director for the advocacy division at Consumer Reports. “It’s really outrageous.”

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In a study last year, Consumer Reports detailed some of the reasons excessively high air ambulance bills have become more common. Use of air ambulances is rising as more rural hospitals close, baby boomers age and the use of telemedicine increases.

“The industry has really grown by leaps and bounds over the last 15 years and prices have doubled or tripled,” Bell said. “Most of the operators of air ambulances now are for-profit, Wall Street-type corporations reporting very large profits to investors.”

The Association of Air Medical Services (AAMS), a trade group, counters that it is not unique, that many hospitals and health insurers across the country are also for-profit and that some are owned by private equity firms.

AAMS said a key reason bills for patients with private insurance plans are often high is this: Companies have to make up for the money they lose transporting other patients.

“Medicare pays about 60 percent of the cost of the flight. Medicaid pays 35 percent or less. Self-paid patients pay a few cents on the dollar. And that has led to a crisis of being able to sustain the service,” Christopher Eastlee, AAMS vice president for government relations, said in a statement, stressing that he has cost data only for emergency helicopter transports, not jets like the one in which Cunningham traveled.

In 2018, Medicare paid $8.65 per mile for a fixed-wing aircraft like the Learjet that transported Cunningham. That’s a stark contrast to Angel MedFlight’s $275 charge per mile. There are no guidelines for determining reasonable charges in this case.

Cunningham’s insurer, CareFirst, initially paid $14,304.55, leaving about $460,420 unpaid. In Massachusetts, a ground-based ambulance could not demand that Cunningham pay the balance, as state law doesn’t allow so-called balance billing. But air ambulances are governed by federal aviation laws. There are numerous cases of companies demanding payments from patients. A few states have tried to intervene but been unsuccessful, with courts saying that federal law prevails.

Cunningham has been focused on recovering her speech and preparing for surgery. In January, she will meet with her doctors to decide which type of surgery they recommend for removing or bypassing the blood clots at the base of her brain.

But Cunningham and her father have another worry: what the mail may bring.

“I don’t know, we’ll see,” Cunningham said, with a shrug.

“It’s a big bill to be sitting out there wondering what’s going on,” said Royer, who contacted KHN-NPR’s Bill of the Month on his daughter’s behalf. “It would force her into bankruptcy.”

Angel MedFlight COO Andrew Bess told WBUR the company is negotiating with CareFirst and will not demand payment from Cunningham.

“We’re quite confident we’ll come to a clear resolution despite the insurer placing the patient in the middle of the dispute,” said Bess.

Royer said it was a letter from Angel MedFlight that sounded threatening. As he read it, the company told Cunningham she must sign over the rights for Angel MedFlight to negotiate with CareFirst or risk being held liable if the insurer did not pay. Cunningham signed the request.

Bell, with Consumer Reports, said agreeing to such terms can be risky. Some air ambulance companies ask for detailed information about the patient’s personal finances, information they then use to determine how much the patient can pay if the insurance reimbursement is deemed inadequate.

During inquiries for this story, CareFirst told WBUR it would increase the proposed payment to Angel MedFlight. The insurer said it had discovered an error in its initial reimbursement to Angel MedFlight. CareFirst is now proposing to pay $70,864.90, or about one-seventh of the original charge.

“Unfortunately, exorbitant charges like these by air ambulance providers are not uncommon,” said Scott Graham, a spokesman for CareFirst, in an email. “This is an issue because companies like Angel MedFlight typically do not contract with health insurers on negotiated rates.”

WBUR forwarded this update to Bess, who called it a “meaningful offer” in his emailed response.

“We provide a valuable service, and for that providers should be fairly compensated and reimbursed,” Bess said. “We strive to work with our patients and advocate on behalf of them to get coverage rightfully owed to them under their insurance plans.”

Royer, a retired Air Force air traffic control systems manager, knows something about the cost of operating jets. To him, it looks like Angel MedFlight inflated the bill, hoping the insurer would agree to a generous settlement.

“I guess that the way things work nowadays. You ask for the moon and if you only get a large island, that’s what you get,” Royer said.

Bess responded to Royer’s claim in a statement.

“Staffing what is essentially an Intensive Care Unit at 30,000 feet presents unique medical and aviation challenges that may not be apparent to those outside of the medical aviation industry,” Bess wrote. “The amount we receive per flight is a fraction of the billed charge.”

Patients caught up in an air ambulance billing dispute can file a complaint with the U.S. Department of Transportation.

A recent push for stricter federal billing regulations was stripped out of the Federal Aviation Reauthorization Act, passed in October. The legislation did establish a council of industry representatives, including air ambulance providers and insurance company representatives, among others, to write and re-evaluate consumer protections, including balance-billing practices. It did not add a requirement for more price and other data transparency called for in a Government Accountability Office report on the air ambulance industry.

The National Association of Insurance Commissioners says federal legislation is needed so that states can intervene to oppose unreasonable air ambulance charges. Lawmakers from rural states, including Sen. Jon Tester, a Montana Democrat, said they’ll reintroduce such legislation.

The air ambulance trade group says any such change would create “borders in the sky” that would interfere with lifesaving air rescues across state borders.

This story is part of a partnership that includes WBUR, NPR and Kaiser Health News.

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