What Counts as an Emergency? Ask Three Different Systems, and You'll Get Three Different Answers

Written By: Asbel Montes, Co-Founder & Managing Partner, SGS

This is the fourth piece in this series. The last one was about rebasing, and it was about dollars. This one is not about dollars at all. It's about a word we use so often in EMS that we stop noticing how many different meanings it carries: emergency.


That word determines whether a call gets covered, whether a patient gets balance billed, and whether a transport even qualifies for payment in the first place. And here's the problem: ask Medicare what an emergency is, ask the Ground Ambulance and Patient Billing (GAPB) Advisory Committee, and ask the federal law that governs hospital emergency departments, and you will get three different answers built for three different purposes that do not line up cleanly with each other.


As Chairman of the GAPB Advisory Committee, I led the discussion that produced a definition rarely found in healthcare. Payers, providers, state regulators, and consumer and patient advocates do not agree on much. This definition, they did: the full committee adopted it unanimously, sixteen votes in favor, zero opposed, one member absent. That’s a rare agreement in our world. So I want to take you inside that conversation, not just summarize the report.


What Medicare Asks


To be covered, ambulance services have to be “medically necessary and reasonable.” Medicare determines necessity by asking whether the patient's condition was such that use of any other method of transportation is unsafe or contraindicated. If some other reasonable means of getting the patient to care could have been used without endangering the patient's condition or health, whether or not that other transportation was actually available, then Medicare will deny coverage.


“Reasonableness” is a separate test, and it matters just as much. Payment is based on the level of service actually furnished, not simply on the level of vehicle that responded. Even if a local government requires an Advanced Life Support (ALS) response to every call, Medicare only pays for the level of service that was medically necessary and furnished. Two related provisions sit alongside that test. A beneficiary is presumed bed-confined if they cannot get up without help, cannot walk, and cannot sit in a chair or wheelchair, but the manual is explicit that bed confinement, by itself, is neither sufficient nor necessary to establish coverage. It is one factor among others, not a test that is simply met or not met. Destination matters, too. Coverage runs to the nearest facility equipped to treat the patient's specific condition, a factor that becomes central when we get to interfacility transports. Also keep in mind that ambulance service providers are required to respond based on third-party information, which can come from (1) the patient, (2) a person with the patient relaying what the patient's condition appears to be through their lens, (3) a first responder such as police or fire, or (4) a medical professional at a facility with the patient. EMS must respond with the level of care called for by what they are told, yet payers are allowed to take a retrospective approach to payment.


The “tests” that determine payment are built to be answered after the fact, by a reviewer looking at a chart (not at the patient), asking whether the transport that already happened was justified.

That works fine for a payment system.

It doesn't work so well for a system that is obligated to remain on emergency standby 24/7/365 and respond based on the information received (level of care, equipment, and training) but only get paid if the patient is transported, and only to the level determined after the fact. 

And it works less well as a definition of what an emergency actually is to the person calling 911, in the moment, before any of that documentation exists.


So we needed a more appropriate standard, one that is patient-centric and built around the decision to call 911 rather than around what happens inside a hospital's four walls afterward.

What GAPBAC Asks

Medicare's “necessity and reasonableness” tests were not built to answer the pivotal question a patient is actually asking before they pick up the phone: is this bad enough to call 911? I often quote Brené Brown, who in her book Dare to Lead, famously said, “Clear is kind. Unclear is unkind.” Patients, providers, and payers had no clear definition, so we built one.

Ground ambulance emergency medical service, in the Committee's recommendation, means medical or transport services furnished to someone for whom an immediate response was required to assess or treat a condition that the person reasonably believed, or that a prudent layperson would reasonably have believed, was an immediate threat to their health and/or physicality requiring ambulance services. And then the line that does the real work: whether that belief was reasonable “shall not be based solely upon a retrospective analysis of the level of care eventually provided to, or a final diagnosis and/or discharge of, the person who received emergency assistance.” 

That sentence exists because we heard the same story over and over, from patients and from providers. Someone calls 911 genuinely afraid. They get evaluated, stabilized, and discharged without a dramatic intervention. Unfortunately, under a purely retrospective standard, that call can look, on paper, like it was never an emergency at all, even though the person calling had no way of knowing that in advance. The EMS provider had no way of knowing that in advance. Or, in some instances, even at the point of delivery of the patient to the ER. EMS is required to respond based on a third party's belief of a medical condition, yet both they and the patient were getting penalized for doing just that “after the fact.”

Why isn't the prudent layperson standard already in federal law?


The short answer, it isn’t. And that gap is exactly the problem the Committee set out to fix. The prudent layperson standard built into the No Surprises Act (NSA) is used solely to determine whether an Emergency Medical Treatment and Labor Act (EMTALA) obligation has been triggered for a particular hospital visit. It is tied to hospital emergency department screening requirements under Section 1867 of the Social Security Act, the EMTALA provisions. It was not designed to reach emergency ground ambulance services. Not because it meant to exclude them, but because the NSA excludes ground ambulance services, so the application was never contemplated. In fact, the NSA's definition of emergency services is not broad enough to cover the totality of the services and care provided by ground ambulance crews, including emergent response, treatment in place with no transport, and interfacility transports to a facility that is not itself an emergency department admission. That is why the Committee built a separate and distinct standard, the prudent person standard, rather than simply borrowing the NSA's.

 What EMTALA Asks

 That last phrase, “not itself an emergency department admission,” is where the third definition comes in, and it is the one I think gets the least attention outside a room full of policy people.


EMTALA is triggered when there is a request for medical care inside a dedicated emergency department, or for emergency care on hospital property outside the dedicated emergency department. It obligates that hospital to screen and stabilize to the best of that hospital's available capability.


So what about the ambulance that is called to transport a patient from one facility to another for continuation of care?


While Medicare's own manual anticipates this scenario directly, there is no clear provision for how this transport is defined. And remember, clear is kind, and unclear is unkind.


When a patient arrives at a hospital that turns out to have inadequate or unavailable facilities for the totality of the care they actually need, and gets transported to a second facility with the appropriate level of care, staff, equipment, and capacity, both legs of that trip are covered, but only to the extent of the mileage to the nearest institution with appropriate facilities. Air ambulance coverage for hospital-to-hospital transport is even more specific: it requires that ground transport would endanger the patient's health and that the transferring hospital lacks the specialized services the patient needs, things like burn care, cardiac care, trauma care, or critical care. Preference for a particular hospital or physician does not qualify.


Now overlay the current No Surprises Act framework on top of that.


Balance billing protections, meant to shield patients from being exposed to financial hardship in an emergency situation, apply only to services connected to a freestanding or hospital emergency department.


If a patient is transferred by ambulance from one emergency department to a unit that admits them without going through a second emergency department, not because the condition is no longer a threat or in need of immediate care to mitigate risk to life, limb, or extreme pain, but merely because the patient bypassed a second emergency department to go straight to the care necessary to adequately treat the patient, the “technical” trigger is deemed not met. The claim can be denied. The patient, who did everything right and was moved because the first hospital could not treat them, and the ambulance provider who brought the patient to the care that was medically needed and urgent, end up exposed. The patient is not protected under the NSA, and the provider is not paid for the level of care provided.


This falls precisely within the purview of what the Committee was formed to address: how do we best protect the patient? Therefore, the Committee's “emergency interfacility transport” definition came into being as: transport by an emergency ground ambulance service provider of a patient with an emergency medical condition from one healthcare facility to another to receive services not available at the originating facility, as ordered by a licensed treating provider.


Whether that patient is being brought into a second emergency department or straight into a cardiac unit that can actually treat them, the underlying reality has not changed. They are still experiencing an emergency. The system's willingness to recognize that should not depend on which door they enter.


Patricia Kelmar, the consumer advocate on the committee, put it plainly during our discussion of the related interfacility transport definition: if you are already inside a hospital that does not have the care you need, “you might as well be in your church parking lot or at home without the care that you need.” The point is not where you are standing when you realize you need help. The point is whether the condition is genuinely urgent.


What This Fixes, and What It Doesn’t


Put the three tests side by side and the shape of the problem gets easier to see.


Medicare asks whether the transport was necessary and reasonable, reviewed after the fact.


EMTALA asks whether a specific hospital obligation was triggered, based on where inside the hospital the request for care was made.


The Committee's prudent person standard asks something closer to what patients actually experience: did this person have a reasonable basis, in the moment, to believe they needed emergency care.


It can be argued that none of these three tests is wrong for the purpose it was built for at the time it was put into place.


It can also be argued that Medicare's retroactive determination is inconsistent with the obligations and standards EMS agencies are expected to operate under. Ground ambulance services, and the patients who use them, are being forced to live and operate inside all three definitions and expectations at once, without ever reconciling them. A transport can satisfy Medicare's necessity standard, fail to trigger EMTALA protections because of where the patient was physically standing, and still be exactly what a reasonable person would have called 911 for.

The Committee's recommendations, including the prudent person standard and the emergency interfacility transport definition, have not been enacted. They are recommendations to Congress and the Secretaries, not current law. Coverage today still depends heavily on which of these frameworks a payer chooses to apply to a given claim, and that inconsistency is where a lot of the balance billing exposure and inadequate payments this whole series has been tracking actually comes from.


Look, I get it: some will argue that a purely patient-perception standard invites overutilization, that if the bar for “emergency” is what a reasonable person believed rather than what a clinician later confirmed, more transports that, on the backend, would not meet medical necessity if hindsight was 20/20, will get billed, and payers could respond by denying more claims outright rather than fewer. That is not a hypothetical objection. It came up inside the Committee's own discussions on cost sharing, where members concerned about overutilization argued for tighter protections, specifically so that expanded coverage would not simply shift the fight downstream.


I do not think that risk means the standard is wrong.


I think it means the standard has to be paired with real guardrails, which is exactly what the Committee tried to do by tying it to medical oversight and documentation requirements rather than leaving it undefined.


Clear is kind. Unclear is unkind.


The next piece in this series is going to come from the other side of that 911 call. I have asked an emergency physician to be my co-author, because everything I have laid out here describes how systems define an emergency after the fact. His piece is about how a clinician actually makes that judgment, and what that process looks like from inside the moment these three definitions are all trying to describe.


The question I opened with was: who gets to decide what counts as an emergency? The next question is: what does that decision actually look like from the clinician's side of it?