Those ambulance and FireFlight rides to the hospital aren’t free: Flagler County Fire Rescue bills those transported through a third party. About 60 percent of those transported pay. For many reasons, not least among them the lack of insurance or sufficient insurance, the rest don’t. It is one of the many shards of the country’s broken healthcare system.
Since 2018, the county has accrued on average $1.7 million a year in what the county considers to be uncollected bills, or $10.3 million through February 2024. It’s happened for years, if not quite by those amounts. For years, the County Commission has periodically written off the loss, as hospitals and other providers do with their own uncollected payments. The last write-off was for $6.4 million.
The large figure is not without a deceptive caveat. Not all those bills the county considers “uncollected” are, in fact, uncollected. The majority are not.
Bills through Medicaid or Medicare, the government health insurance plans, are paid, but at rates set by Medicaid and Medicare. The county doesn’t bill at those rates. It bills higher–and lumps the different into its unpaid balance pot, which deceptively raises the amount owed the county.
“That’s a large portion of this,” Flagler County Fire Chief Michael Tucker told the commission.
In effect, a large portion of the amount the county is writing off is a county construct that partly veils the fact that the county did get paid for those Medicaid and Medicare transports, in a county where nearly a third of the population is on Medicare. Still: the discussion the county commissioners fixed on took little account of Tucker’s caveat and addressed the $10 million as if it were an outright loss that theoretically could have been collected.
County commissioners were required to go through the formality of approving the write-off on Monday. They did so for the $10.3 million uncollected since 2018, but not before Commissioner Leann Pennington asked: “Is there some sort of plan to resolve this dilemma going forward?”
Though it’s not a written policy, the county had previously opted not to throw the unpaid bills to a collection agency. Doing so might have discouraged residents from calling 911 in emergencies for fear of the eventual bill–as a quarter of Americans still don’t over those same fears, according to a 2024 YouGov survey.
“I would like to make some kind of motion to not allow this to happen again,” Commissioner Pam Richardson said. “If there’s somebody in default and we need to have some kind of process in which we can go ahead and attempt for, whether we hire an outside collection agency or whatever we need to do. This is absurd.” Richardson’s motion, if it was one–none of the other commissioners seemed to take it as one–did not get a second.
This year’s amount is large, said John Brower, the county’s director of financial services, due to a data breach at Change Health Care, the UnitedHealth-affiliated company that provides billing for the county. The company, the largest such clearinghouse in the country, was not able to provide billing after February 21, 2024, according to the county (though the write-off amount predates February 2024, and Brower spoke before Tucker revealed the Medicaid-Medicare caveat).
The breach wasn’t a minor issue. “The February cyberattack interrupted operations for thousands of doctors’ office, hospitals, and pharmacies,” the New Hampshire Department of Justice reported at the time. “It also resulted in Americans’ sensitive health and personal data being leaked onto the dark web – a hidden portion of the internet where cyber criminals buy, sell, and track personal information. Although the actual number and identity of affected patients are currently unknown, Change Healthcare has publicly stated that the data breach could impact up to 1/3 of all Americans. This was an unprecedented data breach.”
A ransomware group reportedly stole 6 terabytes of data, or 6,000 gigabytes. It isn’t unusual for computers to have a terabyte of storage. Google’s cloud storage offers from 2 to 10 terabytes of space to individual customers and companies.
In Flagler County, “We were essentially shut down billing for close to six months,” Tucker said.
The county switched to Digital EMS Billing. That company is charging “double” what Change Health Care used to charge, Brower said. “We’re always going to have uncollectibles, nothing close to this. That’s the expectation,” he said. “Their collections, their process, is a lot better than Change Healthcare’s was.”
“So we lost funding because they had had, what, like a cyber attack, data breach,” Pennington said, “and there’s no accountability on their part to pay us for uncollectibles because of what occurred to them?” Brower said the county is “small potatoes in their world,” and if there is to be a reimbursement, it won’t happen for years. That surprised Pennington, given the enormous amount of write-offs.
County Attorney Michael Rodriguez didn’t know the details of the issue or whether a class-action suit had been filed against Change Health Care. “I had a similar instance with a same ambulance billing provider, one of my former jurisdictions, where we did file a lawsuit,” he said. “There were some impropriety concerns. We ended up having to settle the matter just simply to get back our data.”
Commissioner Kim Carney suggested that the county make its adjustments annually. Commissioners agreed to have “insight into other directions,” as Commission Chair Andy Dance said. What those directions will be is unclear. Tucker reminded the commissioners that the issue underscores the fact that ambulance billing is not a money-maker.
Dusty says
Yeah it is that the insurance only pays allowable charges. That is disclosed to medical service providers before they provide the service.
Roy Longo says
We do not need heart patients driving to the hospital just to avoid a collection company, threatening them about a bill. The county needs to give up on collection agencies and accept whatever payment they get. This is a service to the community not a business. Let’s never forget that.
Just call a cab it cheaper. says
Minor bike accident near the Walmart quick ride to advent half mile away “Just to be safe”. Cat scan + couple stitches cost $280. 3 minute ambulance ride? $972. Maybe if their glorified Uber service wasn’t so ridiculously overpriced, more out of pocket folks and insurance companies would pay them. there are legally zero repercussions for not paying, will not affect credit score so can’t imagine why they are behind in their collections.
JimboXYZ says
Maybe the differential of the write off should be something billed to Advent or other hospitals that account for unaffordable healthcare ? Wonder what the Fentanyl 911 calls for the ambulatory to show up and administer Narcan is ? Those drug addicts need to pay for all of their ambulance calls & rides. That is before they buy their next fix of Fentanyl ? If Medicaid & Medicare aren’t reimbursing a payout that covers an ambulance ride to the hospital ? Maybe that ride is overpriced ? Because we all know insurance premiums are on the rise as usual for inflation, regardless of blaming that on Obama/Trump/Biden/Trump. Advent built the Cancer wing for millions, empty parking lot for that location ? Maybe money that should be applied for actually delivering healthcare needs to be provided at a truly affordable price ? There are some infrastructure products & services should be made available at real cost, not what someone wants to be compensated for ? As it is, the Fire Department provides this as part of the taxation budget. So we all paid for the trucks & equipment, the firefighters that are paramedic qualified, that’s a process of EMT training. Part of it might be sponsored by an employer ? Some of it thru a college/university as self funded/invested for any degree/certifications ? What is the true cost ? The education is 6 months at a college ? What is that, a Spring or Fall semester with a Summer abbreviated mini-mester ? And that education should be affordable. Notice the theme here, everything healthcare is unaffordable, even though it’s touted as affordable. From the hourly rates in the link, $ 25/30 is pretty much 1/2 or more of what anyone is supposed to be paid at the current minimum wage, so we know the healthcare industry isn’t paying EMT like they do neurosurgeons ?
https://nurse.org/healthcare/how-to-become-EMT/
Ed says
My place of bussness keeps getting bills for ambulance transport from my store to Advent for a road construction worker who got injured on the job. The bill keeps coming because “That is where he was picked up ” Maybe if correct mailing addresses were used we MIGHT get paid ?
Jojo says
Our taxes buy the equipment and pay the salaries of the EMTs. And now the county wants to complain that some dont pay for these things for a second time?
Give me a break.
Deborah Coffey says
Please change your voting habits, Flagler County residents.
Jason says
Interesting position the author is taking in the article. Essentially claiming that the county got paid and making it sound as though the county is overcharging for these transports because Medicaid and Medicare have a maximum rate they will pay. But not a single word about whether that underpayment is causing any readiness issues for these transports nor a single word or analysis of why the county is charging a rate higher than what the government healthcare will pay.
So now I’m left to wonder if that 10m in underpayment is actually lowering the quality of emergency care or not. Do they have the funds for proper training? So they have the funds for proper maintenance of the ambulances and equipment in them? What would that 10m have been used for if they had actually received it? Is it earmarked for emergency response use only or could it co towards other needs like the infrastructure upgrades costing millions?
Taxpayer says
Something about this sounds fishy.
TR says
@Just call a cab,
I wish people would tell the truth when complaining about something. I believe you’re not telling the full story, your $260.00 amount you mentioned was probably the out of pocket total and not the total for the hospital service you received. Also a little bit of an exaggeration on the ambulance ride. It’s a lot farther than a half mile from Wal Mart to (I’m assuming) the Advent hospital on Palm Coast Parkway. Guessing more like around 2 miles. Also based on your story, the ride only took 3 minutes? That means the ambulance was only going what like 3/4 mph? Maybe the next time you have a MINOR bicycle accident (hopefully you won’t) you will call an Uber and save yourself some money. Good Luck.
Jason says
@TR
The rate is probably accurate. Don’t forget that you aren’t just paying for the mileage. You are paying for the EMTs, the medical equipment used, etc. Mileage is likely not even calculated and the total time they spend responding, treating, and transporting you is what’s being billed.
My wife does medical billing for a large hospital chain and she regularly sees bills from the air transports (helicopters) in the 6 figures.
FLF says
Mom fell and banged her forehead, fair amount of blood, decided to get her to the hospital to make sure she was OK. Called 911 for help, ambulance here in 5 minutes, 5 mile ride to advent was $672, Medicare and coinsurance picked up $375, balance out of pocket. Once at Advent, got her right in for wound care, cat scan, excellent care, 3 hours, back to the house. That bill was $12,000, Medicare paid all but a $100, Since Advent is tax exempt, and non profit, I wonder what the bill would have been if they were paying taxes and “making money”.
DaleL says
The Flagler County Fire Rescue (ambulance bill) includes a mileage charge. Based on a May 2025 ambulance bill, it was $14.00 per mile in May. This is added to a flat charge. The flat charge for an Advanced Life Support (ALS) emergency was $700 in May. However, despite some searching, including the County website and the Fire Rescue website, I have been unable to find the current fee schedule.
If a person pays their insurance deductible amount and includes their insurance information, the billing company seems to ignore the insurance information and continues to bill the individual. Phone calls to the phone number on the bill do not seem to be ever answered. It does not seem to be an efficient system.
In contrast to the billing of a victim of a medical emergency which requires an ambulance, the Flagler County Sheriff conducted an extensive search earlier this year for a missing person in the Hammock. There were helicopters, the canine unit, the whole works. It must have cost a fortune. The guy in question apparently had some sort of mental health issue and wandered off from a house he was building. He showed up at his nearby home after 32 hours. I doubt he was billed for the cost that his medical condition caused the County.
I recommend that the County have an easy to find, published fee schedule for all billable services, including ambulance fees. I would think Florida’s “sunshine” law would require it.
Flagler County does not seem unique in the practice of “soft billing” for ambulance services. I know from many years ago, that Upper Arlington, Ohio had a similar practice. Is it fair? One way or another, those with the means or insurance, always pay for those who don’t. The alternative is to cruelly bill up front and deny life saving services to those who cannot pay.
Rich says
If rick Scott or desantis the current and former idiot governor’s we have had had taken that aca we would all been able to pay or medical bills
c says
So, obviously, none of the Commissioners either (A) Have Insurance or B) Don’t ever read the monthly EOB (explanation of benefits) that most insurance companies put out to their clients when a medical bill is incurred.
If they had, they would realize that almost all medical entities bill insurance at the maximum allowable rate – knowing in advance that they are only receiving a portion of that amount which is allowed (and will reimbursed) by the insurance, plus any stipulated co-pays.
I would really like to know which accounting firm audits the ambulance service, and allows calling this difference a loss?
Rich says
Maybe if our current or former governor had taken the aca this problem wouldn’t exist