The Committee Already Answered the Question. Congress Just Hasn't Acted On It.
Written By: Asbel Montes, Co-Founder & Managing Partner, SGS
This is the third and final piece in this series. The first piece asked what counts as an emergency, and showed that Medicare, the GAPB Advisory Committee, and EMTALA each answer that question differently. The second, written from Dr. Cozzi's seat as an emergency physician, showed what that disagreement costs patients in the space between "stabilized" and "safe," particularly when the emergency doesn't end at the first hospital. This piece is about the solution for both problems. Specifically, it's about the fact that the solution already exists, was already voted on, and is sitting in a report to Congress.
What the Committee actually recommended
I chaired the discussion that produced these recommendations, so I want to be precise about what they are and are not. The GAPB Advisory Committee's final report to Congress, delivered March 29, 2024, included a set of seven new definitions the Committee recommended Congress or the Secretaries adopt. Two of those seven are the ones this series has been building toward. One answers part 1's question. The other answers part 2's.
The first definition: who gets to call it an emergency
The Committee's definition of "ground ambulance emergency medical service" is built around what the report calls a prudent person standard. It is not a rebrand of the prudent layperson standard already used in 48 states and under EMTALA. The federal standard exists to determine whether an EMTALA obligation has been triggered inside a hospital emergency department. It was never built for the person standing in a living room deciding whether to call 911. The Committee's version centers on that person's reasonable belief that the condition was an emergency and required ambulance services, and it states directly that this determination shall not be based solely upon a retrospective analysis of the level of care eventually provided. A payer cannot use the outcome to relitigate the call.
The second definition: when the emergency isn't over at the first hospital
This is the one that speaks directly to what Dr. Cozzi described. The Committee also adopted a definition of "emergency interfacility transport," and the background discussion behind it reads like it was written for his article. The report walks through the exact scenario he raised: a patient arrives at a hospital that cannot provide the level of care they need, whether they got there by ambulance or on their own, and clinicians determine the patient has to be moved again, sometimes from a Level 3 trauma center to a Level 1 for neurosurgery or trauma orthopedics, sometimes just to reach an MRI the first facility doesn't have. The report is explicit that these transfers may constitute an emergency, but are distinguishable from the initial visit, and that under current law, patients routinely lose coverage for that second transport because it didn't technically qualify as an emergency service on its own.
The Committee's definition closes that gap. Emergency interfacility transport now covers the ground ambulance transport of a patient with an emergency medical condition from one facility to another to receive care not available at the originating facility, when ordered by a treating provider. The point isn't the wording. The point is what it does: it treats the second leg of the emergency, the one Dr. Cozzi's whole piece was about, as a continuation of the same emergency rather than a separate, harder-to-justify claim.
Both were adopted without real opposition, and that repeats
The Committee adopted all seven definitions unanimously, with one exception: the definition of "prompt payment," which passed 14 to 1 with two members not voting, over a dispute about a separate payment provision unrelated to either definition discussed here. Neither the prudent person standard nor the emergency interfacility transport definition drew recorded opposition.
That agreement didn't stop at the definitions. When the Committee voted to require coverage of ground ambulance emergency services, it specifically wrote emergency interfacility transports into the coverage requirement and adopted it 14 to 0, with two abstentions and one member absent. When it voted to fold these services into the federal Essential Health Benefits definition, explicitly including emergency interfacility transports again, that passed by the same 14 to 0 margin.
Three separate votes, same near-unanimous result: all recognizing emergency interfacility transport as a part of the emergency and requiring coverage for it.
What this fixes, and what it doesn't
Together, these definitions solve the retrospective-denial problem this series opened with, on both ends of the emergency. If adopted, a payer would no longer be asking whether the initial 911 call was justified in hindsight, and a second ambulance ride to a higher-acuity facility would no longer be treated as a standalone, non-emergency claim just because it happened after the patient reached a hospital.
What it doesn't fix is payment. The Committee was explicit that these definitions have to be read alongside its recommendations on minimum required payment and balance billing, and those did not achieve the same unanimity. It also doesn't fix itself into law. This is a recommendation, not a statute. Nothing here has legal force until Congress or the Secretaries act on it, and eighteen months after the report was delivered, that hasn't happened.
Where that leaves the series
Part one showed three systems answering the same question three different ways. Part two showed what that inconsistency costs a patient in the moments after stabilization, when the emergency isn't actually over. This piece puts the Committee’s answer on the table: two definitions, adopted with almost no dissent, by seventeen people who agreed on very little else in that room.
The Committee did its part. Whether Congress does its part is a separate question, and it's the one this series leaves open.
