By: Michael Achterling

FARGO (North Dakota Monitor) – North Dakota ambulance service providers lost nearly $500 on average for every patient transported to a medical facility last year, according to a survey.

The recent survey of three dozen providers in the state, conducted by PWW Advisory Group, was the result of a study created by House Bill 1322 passed during the 2025 legislative session.  The group presented the results to the Legislature’s interim Emergency Response Services Committee on Wednesday.

The average revenue generated from an ambulance transport was about $1,100 during 2025, but the expenses were nearly $1,600, said Matt Zavadsky, an EMS and mobile health care consultant with PWW, based in Pennsylvania.

“They are losing money every time they respond to a call,” Zavadsky said during the meeting. “That financial loss has to be made up, typically, by local tax subsidies, fundraisers, bake sales, or all too often, service reductions to try and match expenses with the revenue they can generate.” 

He said the problem cannot be fixed by billing reform alone because the revenue generated isn’t enough to fund the cost of readiness, such as personnel, equipment and supplies, among other items.

The survey highlighted 74% of ambulance provider expenses went to personnel costs, but equipment costs have also increased in recent years.

Zavadsky said survey respondents plan to invest about $12.9 million into vehicle and equipment purchases over the next five years, averaging to about $358,000 per provider. However, the cost of a new ambulance has risen to between $275,000 to $480,000 per vehicle. Prior to the COVID-19 pandemic, a new ambulance could cost up to $250,000, he said.

There are more than 100 ambulance service providers in North Dakota. The 36 survey respondents represented a diverse group of providers from city and county services to district-owned, hospital-based and private providers, he said. The average patient transport distance is 34 miles, according to the survey.

Zavadsky said the survey respondents reported 53% of their total revenue was generated from fees for service with the remaining 47% coming from local tax subsidies, state grants and other fundraising.

“What you guys are experiencing in North Dakota and what is happening in the local communities … is not the fault of the local communities, not the fault of the state, this is just our new normal,” Zavadsky said.

Rep. Todd Porter, R-Mandan, owner of Metro-Area Ambulance Service which serves Morton and Burleigh counties, said Medicare patients reimburse ambulance providers at a much lower rate than private insurance and Medicaid patients. He added Medicare patients make up about 60% of the call volume in the Bismarck-Mandan area.

“If we’re being underpaid for 60% of our call volume, then we have to make it up some place,” Porter said.

He said some providers can make up that difference in reimbursement with tax dollars, but not all providers have that option.

“We do other contracted work for nursing homes, hospitals, funeral homes in order to make up that difference,” Porter said. “This is a federal government problem. This is a CMS (Centers for Medicare and Medicaid Services) problem that we’ve known about for years.”

Porter also said ambulance services are not reimbursed for responding to a call with a Medicare patient that doesn’t require a transport to a hospital. According to the survey, about 17% of all ambulance calls don’t require transport to a medical facility.

The survey also showed about 2,300 of the nearly 33,600 patient transports billed last year ended up in collections after being more than 90 days delinquent, totalling $2.7 million, Zavadsky said. The average total of a claim sent to collections was about $1,100.

Zavadsky estimated the total of unpaid claims for more than 100 providers across North Dakota was about $5.8 million in 2025. Some providers don’t have procedures to pursue delinquent billing in collections, he said.

Rep. Jim Grueneich, R-Ellendale, chair of the committee, said the committee will take a deeper look at the data presented on Wednesday and may have recommendations, and possible draft legislation, to address the issue in the 2027 legislative session.