Expert EMS Billing

How EMS Leaders Build Cultures That Drive Performance

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Creating a culture of excellence requires EMS and Fire Service leaders to take an intentional approach to blending optimal clinical outcomes, meaningful continuing education, consistent compliance, and thoughtful organizational management.  

In our recent webinar, More Than Mandatory: How EMS Leaders Are Building Cultures That Drive Performance, we asked a panel of experts to share how they guide their teams to balance everyday challenges with building a culture that can sustain a thriving agency. 

Across three very different organizations—Area Ambulance Service in Iowa, Plum EMS in Pennsylvania, and the Oklahoma City Fire Department—these leaders described culture not as a side initiative, but as a core operational strategy. Their message was consistent: Strong culture doesn’t happen by accident. It is built deliberately, reinforced daily, and led from the top. 

Leadership Sets the Tone 

The conversation opened with a reality familiar to EMS leaders everywhere: The job has never been more complex. Agencies are navigating workforce shortages, financial pressures, evolving clinical demands, shifting regulations, and the cumulative mental strain placed on providers. 

Our panelists agreed that in a constantly shifting landscape, culture is a vital stabilizing force, shaping how EMS teams respond to challenges. Across the board, it was agreed that leadership needs to set the tone to ensure a culture in which employees feel supported rather than burned out.  

“We can talk about culture all day,” said Jennifer Zahrt, CEO of Area Ambulance Service, “but if we’re not out front setting the example, it’s just not going to take root.” 

Oklahoma City Fire Department Chief Richard Kelley emphasized the importance of authenticity in leadership, as culture shows in how leaders communicate, how they handle challenges, and how visible they are to their teams.  

“People don’t care how much you know until they know how much you care,” Kelley said, underscoring a philosophy that prioritizes trust and connection as the foundation of performance. 

All three panelists emphasized the role of transparency in building that trust. Rather than limiting access to information, the leaders described a deliberate effort to share everything from financial data and operational performance to areas where leadership needed to improve. At Area Ambulance, regular town halls provide a forum for employees to ask questions directly, with no topics off-limits. At the Oklahoma City Fire Department, engagement surveys and open communication channels allow leaders to identify employee concerns and respond in real time. Ultimately, the goal is not just to inform, but to align with those they are leading. 

Defining Standards and Holding to Them 

While culture is often discussed in broad terms, the panelists emphasized the importance of making it concrete through clear expectations. 

At Area Ambulance, that clarity is distilled into a simple but powerful mindset designed to avoid fruitless venting and promote action: “Fix it or forget it.” Team members are encouraged to either take ownership of a problem by finding a solution or to let it go, eliminating the kind of subtle negativity that can quietly erode culture over time. 

More broadly, Zahrt framed accountability not as a punitive measure but as a cultural strength—a call to the standard. In EMS environments, where much of the work happens without direct supervision, that distinction matters. Adhering to a cultural standard becomes the guide that informs decision-making, reinforces expectations, and shapes how individuals respond under pressure. 

Or, as Zahrt put it: “What happens when nobody’s watching is what determines your outcomes.” 

Plum EMS Director of Operations Brian Maloney says his agency puts focus on collaboration and continuous learning to create a culture where employees take initiative and pursue excellence together.  

“We try to create an environment where people feel supported rather than scrutinized,” he said, adding that the result has been improvements in clinical performance, documentation, and patient satisfaction. 

Measuring Culture Like Any Other Priority 

Another key theme of the discussion was measurement. Culture, the panelists agreed, should be evaluated with the same rigor as clinical or operational performance. Chief Kelley said Oklahoma City Fire leverages engagement surveys to track employee sentiment and identify areas for improvement. At Area Ambulance, Zahrt’s team uses structured “people metrics” to assess trust, accountability, and leadership effectiveness. Low scores in areas like trust or accountability are treated as signals, prompting conversations, guiding training, and informing leadership decisions.  

Over time, data measurement and tangible responsiveness reinforce credibility and demonstrate that feedback leads to change. It can also create a culture that people want to be a part of, according to Maloney. 

“In the history of Plum EMS, we’ve only posted to hire for a position once. We’re lucky to have always been fully staffed and if or when someone does resign, we have good quality people in the pipeline,” he said. “It’s one of the things the culture and the people here have created, and I can’t give them enough credit for it.” 

A Continuous Commitment 

Finally, all three panelists agreed that building agency culture isn’t a one-time initiative. It requires ongoing attention, focused on finding ways to connect leadership, teams, operations, and outcomes. 

“There’s no magic recipe,” Zahrt said. “If you’re not proactively driving your culture, you’re going to fall behind.” 

To catch the full panel discussion, you can watch the webinar on demand.  

Advocacy in Action: EMS Day on the Hill 2026

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On March 26, 2026, more than 350 EMS leaders, advocates, and supporters gathered in Washington, DC for EMS on the Hill Day, an annual advocacy event. Members of the Digitech team accompanied agency representatives, spending the day meeting with Senators and House Representatives to garner support for current legislative bills that impact our industry.  

Together, we brought a unified message to Capitol Hill, advocating a slate of legislative priorities designed to modernize care delivery, strengthen the workforce, and ensure the long-term sustainability of emergency medical services. Among the top priorities this year were legislative bills focused on Treatment in Place (TIP), Mobile Integrated Health (MIH) and Community Paramedicine (CP) programs, as well as rural EMS agencies.  

Here are a few highlights of the legislative priorities: 

Treatment In Place and Mobile Integrated Health 

At the forefront of proposed legislation is the Comprehensive Alternative Response for Emergencies (CARE) Act, which would allow EMS providers to be reimbursed for treating patients in place; an important shift toward more flexible, patient-centered care that reduces unnecessary hospital transports while still supporting agency revenue. Despite the demonstrated benefits of such methods, funding remains a roadblock for agencies. One National Association of Emergency Medical Technicians (NAEMT) study found that 38% of MIH-CP programs across the country that had ceased operations over a three-year period attributed their closure to funding, staffing, or resource shortages. In addition to the CARE Act, however, the complementary Community Paramedicine Act would expand Mobile Integrated Healthcare (MIH) programs through federal grants, enabling EMS agencies to play a larger role in preventive and community-based care, particularly in underserved areas. 

Rural EMS Support 

Sustainable funding remains a critical concern for rural providers, particularly in the face of rising costs and increasing hospital closures. According to the National Rural Health Association, nearly 50% of rural hospitals in the United States are operating with negative margins, leaving them vulnerable to closure. When a rural hospital closes, the surrounding communities lose access to vital care, often leaving EMS agencies to fill the gap. Continued investment through Supporting and Improving Rural EMS Needs (SIREN) Act grants would deliver essential resources for training, equipment, and operations to agencies that often serve as the only healthcare access point in their communities. 

Prehospital Blood Transfusion 

Another focus was the ability to administer blood in the field; an increasingly vital practice in rural and outlying communities where transport times to the hospital can stretch or that represent logistical challenges. The improved outcomes and real-life examples of such practices are clear. According to the National Highway Traffic Safety Administration (NHTSA), severe bleeding is the primary cause of preventable fatalities in trauma patients, but with the prompt delivery of prehospital blood, it’s estimated that 37% of trauma patients with severe bleeding could be saved; and that for every minute of delay in administering blood, the risk of death increases by 11%. Yet despite the documented benefits of administering blood in the field, the EMS reimbursement structure hasn’t been updated. The proposed Reimbursing Emergency Services for Critical Use of Emergency Blood (RESCUE) Act addresses this financial gap by ensuring EMS agencies are reimbursed for administering blood in the field, helping expand access to lifesaving prehospital interventions. 

National Recognition and Support 

Finally, EMS leaders emphasized the importance of recognition and advocacy at the national level, first with the Honor Our Emergency Medical Services bill which seeks funds and backing to establish a National EMS Memorial. Similar to our national fire and police memorials, the new memorial would honor those EMS personnel who have died in the line of duty. Continued support for the Congressional EMS Caucus was also emphasized, ensuring these and other industry priorities have a strong, bipartisan voice in Washington to help promote, educate, and increase awareness among decision-makers on the federal EMS policy. 

Together, the initiatives at the center of EMS Day on the Hill 2026 reflected a comprehensive approach to advancing EMS, addressing some of our industry’s key challenges, and laying the groundwork for a more resilient, responsive system of care.

EMS Budget Navigation in Uncertain Times

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How do you budget when there are unprecedented changes occurring? Many EMS agencies find themselves facing this dilemma as their industry navigates various legislative changes with unclear impacts.

And the shifts aren’t stopping anytime soon; there are certain to be additional changes on the horizon.

Let’s consider this:

  • We’re still waiting to see how the impact of the One Big Beautiful Bill Act of 2025 (OBBBA) will impact Medicaid coverage over the next several years, given its 9-year phase-in.  
  • As of early 2026, healthcare subsidies for Affordable Care Act (ACA) insurance plans have lapsed.  
  • Government shutdowns have put Medicare ambulance add-ons at risk; however, on this there is a reprieve through 2027 based on the delayed budget passed in early February.  
  • What, if any, impact the No Surprises Act will have on ground ambulance providers is still pending a decision by Congress.  
  • Cost reporting as part of the initial Ground Ambulance Data Collection System mandate by CMS is complete, but how that data will be utilized by MedPAC, and whether there will be any changes to Medicare allowances at some point in the future, is unclear.  

Then there are state level changes. Many states have passed Ambulance Balance Billing legislation or are considering it. Medicaid Ambulance Supplemental Payment Programs exist in a number of states, but there is uncertainty about how those might be impacted by OBBBA.

Now that our heads are sufficiently spinning, it’s time to step back and take a more prudent approach to planning. There is no doubt that the uncertainty level has increased, but the exact impact of everything occurring isn’t known—and the timeline for the changes to occur is playing out over months and years, not days.

What advice can be given to people or businesses facing this sort of financial uncertainty? Here are four tips.

1. Take a more conservative approach to planning for revenue streams.

For example, if your agency’s revenues have been increasing at an average rate of 5% for the past five years, perhaps it is time to project them to be flat for your upcoming budget year. This will likely be questioned by your stakeholders, but sharing what is known to be happening, such as the upcoming cuts to Medicaid coverage and the loss of ACA subsidies, points to a reduction in patients with medical insurance and more that are uninsured.

Do you want to quantify that? You or your billing partner should easily be able to model the impact of a modest reduction of Medicaid and Commercially insured patients, for example, of one percentage point each by shifting those two percentage points into Self Pay.

By modeling a few tweaks, you accomplish a couple of things: First, you signal to your stakeholders that there is some uncertainty on the horizon. You can explain that the exact impacts are unknown, but that it is expected that there will be downward pressure on reimbursement, all else equal. Second, you start to build some buffer into your budget. If the drop ends up being twice as much as you planned for, the gap would be half of what it would have been if you had not planned for a modest change.

2. Assess possible mitigation strategies

If you believe that there will be downward pressure on your core revenues, now is a good time to look at whether there are steps your agency might be able to take to counteract those reductions.

For example, when is the last time you assessed your ambulance fee schedule? How do your fees compare with other providers in the surrounding area? Even though increasing fees only drives additional revenue from patients with Commercial insurance, it does provide an opportunity to offset reductions due to factors outside of your agency’s control. Is your agency billing for treatment and no transport encounters? Again, this might be something to consider to provide some additional revenue for the agency.

Granted, most options come with trade-offs and require navigating community and political considerations, but by laying out some possibly offsetting actions, your agency’s key stakeholders will appreciate that your team is not just talking about lost revenue without providing some off-setting options.

3. Consider contingencies

It is best to avoid being caught off guard by something that was signaled but not fully foreseen. If you planned for a modest reduction in your patients’ Commercial insurance coverage due to ACA subsidy elimination and it ends up having a bigger impact, what will you consider to offset those revenues losses? Perhaps it‘s as simple as communicating early on with your stakeholders so they can plan accordingly. How about setting up a billing/revenue dashboard and committing to monitoring it monthly in order to detect trends early on?

What if you are forced to offset some of your revenue decreases with expenditure reductions? Start thinking about what might be achievable, and over what timeframe those changes can be implemented. For example, can you tweak your response model to only send an ambulance and not a fire apparatus on low acuity calls? Can you utilize nurse triage to address low acuity calls to avoid having to put another ambulance in service? Can you implement a fee for non-transport calls to discourage callers from viewing an ambulance response as a free service?

Very few approaches can be implemented quickly, so some pre-planning is key. Another valuable approach is to reach out to agencies in your area and regional associations to see what priorities they are considering. You might find areas for collaboration and find ways to open revenue options that can be pursued collectively, such as state-level balance billing legislation which supports provider reimbursement.

4. Advocate your value and needs

Approaching your key stakeholders once you are experiencing shortfalls is often too late. Now is the time to share details such as the high costs related to 24/7 readiness and your community’s demand for rapid response during a medical emergency. This advocacy needs to be at the local, state and federal level as well as with other participants in the healthcare eco-system (e.g., hospitals and insurance companies).

Share your cost data with political leaders and explain how Medicaid and Medicare reimbursement rates typically do not cover your costs. Explain to them why a Medicaid Ambulance Supplemental Payment Plan is so vital or why the GADCS collected data really needs to drive reimbursement reform for Medicare payments. This advocacy can be both for the shortfalls on transports and for the fact that there are numerous calls your agency responds to where patients are not transported and no reimbursement is received from most Payers.

This sort of education could also create pathways for reimbursement options for alternative services such as Community Paramedicine and Mobile Integrated Health. In the end, your agency exists to service your community and all you are asking for is the funding to provide the best care possible.

Whether the number of changes that have occurred over the past couple of years is unprecedented or the new normal, our industry needs to be prepared. This is no different than the preparation that is done for the unknown, next 911 call. We need to be prepared for that urgent/lifesaving call at any moment. We do that clinically by having the right personnel, equipment and training so that we are ready. For budgeting, we need to similarly invest time to be prepared to financially navigate the inevitable changes to our revenue streams.

It is time for EMS agencies to plan for the financial unknown.

No ACA Subsidies? What EMS Providers Need to Plan For

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It’s becoming more likely that a solution or compromise to provide subsidies for lower income individuals to afford Affordable Care Act (ACA) insurance plans through State Marketplace Plans will not materialize. Although the exact impact is unknown, there are estimates as to what the reductions might entail.  

Why does this matter to EMS agencies?

Typically, the highest reimbursement for patients served by EMS agencies comes from those with Commercial insurance plans. If individuals are unable to afford Marketplace insurance without some financial support, they are most likely to become uninsured, and the reimbursement for uninsured patients is only pennies on the dollar. 

Let’s look at some of the early numbers since the subsidies have already lapsed for 2026, absent an unlikely deal achieved by Congress:

  • Per data published by CMS on January 28, 2026, about 23 million people signed up for individual market health insurance through one of the States’ Marketplaces.  

  • Open enrollment ended on January 15, 2026.  

  • The 23 million is down from 2025’s number of 24.2 million or about 5%, which is material but not substantial.

At a glance, it would seem like the revenue impact on any given EMS agency would be modest; however, a big concern isn’t just the 5% drop. Just as important is whether individuals begin to drop out of their plans by not paying their premiums if they find themselves unable to afford the monthly payments. Some third-party industry parties such as KFF have estimated that the ACA Marketplace drop would include close to 2 million people, possibly more. 

For any agency it’s not a simple as saying, “OK, if I plan for an 8% reduction in Commercially insured transports, that will give me a good idea of my at-risk revenue.” This is because some geographic locations have more enrollees than others. If you only look at the top 5 States with Marketplace enrollees, there is some tie to population, but not entirely.

State Marketplace Enrollees (2026 in millions)
Florida 4.5
Texas 4.2
California 1.9
Georgia 1.3
North Carolina .8

Therefore, agencies located in these States would feel more of an impact. Additionally, locality within the State will have an impact. The people most susceptible to dropping insurance are typically lower-to-middle class individuals who make too much money to qualify for Medicaid, but not enough money to comfortably afford their various living expenses. As a result, they’re forced to make trade-offs about spending money on housing, food, healthcare, transportation and various other living expenses. 

How can EMS agencies prepare?

Agencies are going to need to account for this shift in the insurance coverage of their patients. As an illustrative example, let’s use the 8% drop in Commercially insured individuals mentioned previously:  

  • For an agency that does 10,000 transports annually and has 15% of its patients with Commercial insurance coverage, that translates to 1,500 commercially insured patients.

  • If 8% drop out, that’s 120 people.

  • If the average reimbursement for a Commercially insured patient is $1,250 versus $50 for someone without insurance, you could expect a drop of $1,200 for those 120 patients or a $144,000 annual decrease.

  • If your agency is four times bigger, that’s over a half million dollars in reduction.  

You should be able to calculate the possible impact on your agency by asking your billing company to pull your numbers, similarly to above, and provide the impact at various reduced levels. 

As Digitech has been stating for quite some time, we expect most of these impacts to occur gradually versus having an immediate drop; however, over the course of the next year, it is important to pay attention to the trends so that your agency can plan accordingly. 

Perhaps a lifeline will be given to people relying on the Marketplace plans by Congress, but the current uncertainty suggests that a prudent approach is to plan for a gradual decline in revenue from your Commercially insured patients. 

Promise and Pitfalls of MIH in NC: Building Sustainable Community Paramedicine Programs

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Across North Carolina, EMS agencies are expanding their mission beyond emergency response by piloting Mobile Integrated Health (MIH) and Community Paramedicine (CP) programs. These initiatives have the potential to transform community health, reduce unnecessary emergency department visits, and improve patient outcomes.  

Success Story: Durham County EMS 

Durham County originally launched a community paramedics program to follow up with opioid overdose patients, providing them with education, access to medication-assisted treatment and detox centers, and Narcan. Today, they’ve expanded to include fall prevention and vaccines for homebound patients, working via referrals from EMS crews, DSS Adult Protection Services, the Duke Outpatient Clinic, and other sources. 

They also raise an important question: How do you fund and sustain them? 

A New Model of Care for North Carolina EMS 

EMS agencies in several parts of the state — including Durham County and other early adopters — are testing MIH and CP models that extend paramedic care into homes, clinics, and alternative destinations such as mental health facilities. 

Typical services include:

  • Post-discharge follow-ups to prevent readmissions
  • Home safety checks for frequent callers or at-risk patients
  • Vaccinations and chronic condition monitoring
  • Transport to behavioral health or urgent care centers instead of emergency departments

These programs help fill gaps in the healthcare system by using the trusted presence of EMS to reach patients who might otherwise fall through the cracks, driving positive impact for communities, hospitals and public health departments, and most importantly, patients.  

The Financial Challenge: How Do Communities Fund MIH / CP Programs? 

While such initiatives improve outcomes, they often don’t fit traditional billing models. Most payers, including Medicare and Medicaid, reimburse only for emergency transports to hospitals, not for non-transport services or alternate destinations. Even commercial insurers do not consistently pay for non-traditional EMS services, but can be receptive if it better serves their member and saves money. 

That leaves many agencies relying on grants, local funding, or hospital partnerships to sustain their programs. In North Carolina: 

  • There is no standardized mechanism for billing community-based follow-up visits.
  • Payers may not pay for services provided by MIH practitioners (e.g., community paramedics are often not recognized as valid providers of services that advanced level practitioners are approved for).
  • Denials are common when documentation doesn’t align with payer definitions of medical necessity or eligible service codes.

For agencies already stretched thin, the lack of reimbursement clarity can make MIH and CP programs difficult to justify financially, even when their community benefit is clear. For the best shot at building a sustainable model, EMS leaders must plan effectively.

5 Questions agencies considering a CP/MIH program must ask:

  1. What services will your MIH/CP program offer? Options include home follow-ups, chronic disease check-ins, alternative destination transport, behavioral health outreach, frequent user mitigation, and more.
  2. Which payers will you attempt to bill? Check with other providers and associations if your local Medicaid MCOs, commercial carriers, or Medicare contractors have defined codes or contracts for these services.
  3. How will you document and code the service? Determine what visits count as “non‐traditional.” Outline how you’ll track them and capture data needed to justify payment?
  4. Will you have internal financial tracking for cost vs. reimbursement? Model the staffing, vehicles, supplies, oversight, training costs as well as project reimbursement sources so you can forecast the program’s sustainability. Don’t forget to identify cost mitigation.
  5. How will you engage your community and healthcare partners? Form partnerships with hospitals, primary care, behavioral health, public health, and social services by illustrating the value of the services you intend to provide.

Looking Ahead: Aligning Innovation with Sustainability 

North Carolina is one of many states examining a shift toward integrated, preventative EMS care. As agencies across the state evaluate cost-based reimbursement models and supplemental funding options for such innovation, their ultimate success will depend on multiple factors, including clinical excellence, data discipline, and advocacy. By collecting the right data, building strong partnerships, and pushing for payment reform, North Carolina EMS agencies can help to scale and integrate community-driven programs. 

 

Whole Blood in EMS: Lessons in Life-Saving Innovation and Financial Considerations

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Groundbreaking clinical innovation is taking hold in agencies from Georgia to California as EMS providers increasingly carry and administer whole blood in the field. What once seemed like an aspirational extension of military medicine is quickly becoming a realistic option for civilian agencies, bringing hospital-grade trauma care directly into the prehospital environment. 

The positive impact on patient survival rates is measurable. Still, launching a whole blood program isn’t simply a clinical decision. It’s a structural, financial, and organizational commitment that requires coordination at every level. Agencies exploring the idea often find themselves inspired by the lifesaving potential but overwhelmed by the operational and fiscal realities that accompany it. 

Setting the Standard: Ventura County’s Whole Blood Program 

At Digitech’s inaugural Frontlines and Bottom Lines EMS Innovation and Monetization Summit in Costa Mesa, California, presented in partnership with First Due and Bound Tree, attendees heard a firsthand whole blood case study from the Ventura County Fire Department. 

VCFD Whole Blood Program Manager Edward Campana described a multi-year planning process that involved his agency, the Ventura County Medical Center, Vitalant blood donation services, and Ventura’s EMS agency. Together, the stakeholders collaborated to develop cohesive policies, training, and oversight. Crews participated in simulation-based competency evaluations and refrigeration systems were rigorously tested. The program officially launched in April 2025, and to date, VCFD has completed 26 field transfusions with no complications.  

Ventura County’s success is rooted in multiple, mutually reinforcing factors. Every case undergoes interdisciplinary QA review, and quarterly data reviews track usage patterns, reaction rates, wastage, and patient outcomes, allowing continuous refinement of both protocols and training. On a logistics level, cold chain integrity relies on validated refrigeration and strict rotation cycles, while continued education focuses on simulations to ensure readiness for relatively infrequent situations. Future plans include enhanced public messaging to educate community members and promote local blood drives. 

Financial Sustainability: The Reimbursement Factor 

While whole blood programs clearly improve patient survival rates, they also introduce ongoing costs that agencies must be prepared to sustain. The reimbursement pathways for whole blood programs are currently narrow. Medicare allows the use of blood products in EMS to qualify reimbursement from an ALS level to an ALS2 level. Some agencies have begun evaluating adding a supplemental charge to allow additional reimbursement for these expensive products from Commercial health insurers. 

An important aspect of tracking the usage of blood products is standardized documentation templates embedded in ePCR systems. Through specific prompts, responders can support whole blood rationale by linking the intervention to the patient’s clinical condition, vital signs, shock indicators, and reason for transfusion. 

Tracking cost and outcome data is important since there is increased discussion on tying reimbursement to patient outcomes. Given the drastic improvement in patient outcomes when whole blood is utilized in the pre-hospital setting, this is an area EMS agencies can utilize to make the case for additional reimbursement. 

Key Considerations for EMS Leaders 

For agencies considering a whole blood program, the main takeaway is that operational workflow requires a substantial investment, but that investment brings a substantial benefit to trauma patients in urgent need of blood. Ventura County is a prime example of what is achievable when a program aligns clinical infrastructure, hospital and blood bank partnerships, training and QA programs. They are just now beginning to explore a billing strategy that provides some financial support. With these factors in place, agencies are positioned to set new standards in prehospital trauma care while seeking revenue that supports it. 

 

5 Best Practices for the North Carolina Debt Setoff Program: What EMS Leaders Should Know

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You may already be familiar with North Carolina’s Debt Setoff Program. Managed by the NC Department of Revenue, the program allows government-operated EMS agencies (or their billing partners) to recover unpaid transport bills by intercepting state tax refunds or state lottery winnings owed to the patient.  

Why does it matter now more than ever? 

In an environment where reimbursement pressures are constant and in flux due to changing Medicare, Medicaid, and insurance landscapes, programs like Debt Setoff can play an important role in supporting agency sustainability. The recovered revenue can fund operations, equipment, and community initiatives that ultimately benefit the public. 

How does it work? 

  1. Unpaid accounts are submitted to the Debt Setoff Clearinghouse, which matches those debts against state databases. 
  2. If a match is found, a portion of the patient’s tax refund or other eligible state disbursement is redirected to the EMS agency to cover the outstanding balance.
  3. The recovered funds are then transferred back to the agency—creating a low-cost, high-yield method of reclaiming revenue. 

The program offers a low-cost, high-yield recovery option that many North Carolina counties use to reclaim revenue that would otherwise be lost. Several counties have already adopted this approach, successfully recovering thousands in lost EMS revenue each year. 

5 Best Practices for NC Debt Setoff Success 

While North Carolina’s debt setoff process is managed by the state, agencies still bear responsibility for ensuring that participation is ethical, accurate, and compliant. Here are five ways to make sure your agency is optimizing the opportunity in a conscientious and mindful manner:  

1. Follow All Applicable Regulations

Though it’s a government-run process, participating agencies still need to follow both state and federal debt collection regulations. This includes the Fair Debt Collection Practices Act (FDCPA), even if your agency isn’t technically classified as a debt collector.

2. Verify Patient Information Thoroughly

Before submitting a debt, confirm the patient’s identity and verify all relevant account details. Misidentifications or ambiguous terms like “Estate of..” or “Heirs of..” can lead to disputes or delays, so maintaining accurate and well-documented records is key.  

3. Safeguard Patient Data

Submit only the minimum necessary data to the Clearinghouse and use secure file transfer methods with proper encryption. Protecting patient privacy is not just a regulatory obligation; it’s a trust imperative. Send required letters promptly and retain proof of mailing, even if they are undeliverable. 

4. Communicate with Compassion 

Proactively, agencies may publish notices to encourage payments before setoff, which can prompt payments and reduce administrative workload. Once notified of a debt setoff, however, patients can be surprised or even alarmed. They may not have realized they had a remaining balance. To minimize anxiety, use clear, respectful, and empathetic communication to explain the situation, offering support or options when appropriate.  

5. Work with Experienced Partners 

If your agency uses a billing partner or vendor, choose one familiar with NC Debt Setoff Clearinghouse requirements. The right partner can ensure data accuracy, compliant notices, and proper documentation throughout the process. 

The North Carolina Debt Setoff Program represents a smart, compliant, and community-conscious way for EMS agencies to recover outstanding revenue. To learn more about it, visit the state’s website at www.ncsetoff.org. 

 

How California EMS Agencies are Navigating a Changing Reimbursement Landscape

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Digitech’s inaugural Frontlines and Bottom Lines summit in Costa Mesa, California featured a session on The California Reimbursement Landscape. Below are insights from what was a valuable and interactive discussion.

As in many states across the U.S., agencies in California are facing a complex reimbursement environment shaped by federal budget fluctuations, evolving Medicaid structures, and rising concerns about underinsured populations. These challenges aren’t isolated policy shifts; they’re increasingly defining the operational realities for EMS and Fire Service leaders. 

At Digitech’s inaugural Frontlines and Bottom Lines EMS Innovation & Monetization Summit, presented in partnership with First Due and Bound Tree, the California reimbursement landscape emerged as a dominant theme. Lively interactions between our industry expert speakers and attendees whose agencies are living the realities underscored a clear narrative: California EMS is bracing for structural changes in how ambulance services are funded, and the strategies they deploy now may determine their financial stability for years to come. 

Cost Reporting and the Medicaid Gap 

Central to the discussion was California’s approach to closing the Medicaid reimbursement gap. For public providers, Medi-Cal transports often reimburse far below the actual cost of service, shifting financial responsibility to local taxpayers. As such, cost reporting programs like California’s Ground Emergency Medical Transportation (GEMT) model remain one of the state’s most important tools for recovering these losses. 

The GEMT program’s evolution has tracked significant shifts in Medicaid’s structure. At the same time, managed care has overtaken fee-for-service models; California’s adoption of a “Rogers rate” methodology has helped standardize reimbursement expectations across regions and provider types. More importantly, it has streamlined cost reporting, reducing the administrative burden on agencies while preserving access to federal matching funds. 

These developments signal a larger trend: Reimbursement reform that once depended on fee-for-service frameworks is rapidly adapting to the dominance of managed care, forcing EMS leaders to rethink long-standing financial assumptions. 

ACA Subsidy Changes and the “Underinsured” Patient 

Another emerging pressure point is the shifting landscape of the Affordable Care Act (ACA) subsidies. While projections suggest thousands of Californians may lose insurance altogether if federal subsidies are reduced or expire, analysts argue that the more pressing concern may be the rise of the “functionally uninsured” patients; those who carry coverage but face deductibles so high that they cannot meaningfully use it. 

For EMS agencies, this distinction matters. High-deductible plans often translate to unpaid balances and increased collections burdens. As more individuals turn to lower-tier ACA plans to manage rising costs, agencies may see a growing segment of transported patients responsible for 100% of their ambulance bill, an outcome that destabilizes revenue while negatively impacting the patient care experience and placing the financial burden on vulnerable households. 

Federal Changes and GEMT Stability 

Federal policy provisions in the One Big Beautiful Bill have raised questions about the future of supplemental payment programs in many states, including California. However, early assessments suggest that the GEMT structure in California is less likely to face immediate disruption. 

This is because GEMT funds flow exclusively to public providers and are designed to offset the gap between Medi-Cal reimbursement and the true cost of service. As such, the program relies on a long-standing federal commitment to match state expenditures for Medicaid-covered care. Unless that underlying commitment changes, the supplemental funding mechanism should remain intact. For many local agencies, this assurance offers rare stability in an otherwise unpredictable financial climate. 

A Sector Preparing for Structural Shifts 

Overall, the themes emerging from California’s EMS leadership conversations reflect deeper national trends. Cost pressures tied to Medicaid, the growth of high-deductible plans, and fluctuating federal priorities are reshaping how agencies plan, budget, and deliver care. For public EMS systems already operating at the crossroads of essential public health functions and financial constraints, the ability to adapt will be essential. California’s evolving reimbursement strategies, particularly through programs like GEMT, may serve as a roadmap for other states confronting similar gaps. 

Checking the Numbers: How Federal and State Regulatory Changes Cause Subtle Shifts in EMS Reimbursement

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When you glance at your smartwatch at the end of a shift, the numbers often look fine. Heart rate steady, steps hit, oxygen levels normal. The real story is in the trends. A resting heart rate that inches upward week after week or a sleep score that keeps sliding may not set off alarms right away, but they are signals worth paying attention to before they turn into larger problems.

The same is true for the One Big Beautiful Bill Act (OBBBA) and recent Medicaid changes. They’re not collapsing EMS budgets overnight, despite what the loudest headlines claim. Coverage and reimbursement patterns are shifting gradually, and the effects vary from state to state and community to community. For EMS leaders, the challenge is to keep an eye on those signals, track how they develop, and prepare for the direction they point to over time.

History Shows the Pace

Digitech believes that looking at historic changes in healthcare coverage offers a clearer picture of what OBBBA’s impact might actually look like. Two examples stand out: the Medicaid unwinding process after COVID when states resumed normal eligibility requirements, and the enhanced subsidies that made Affordable Care Act (ACA) Marketplace plans more affordable. These show that changes are likely to occur relatively slowly, can shift direction over time, and impact states and communities in very different ways.

Medicaid Unwinding: A Patchy Drop in Coverage

Medicaid “unwinding” is the term for states returning to normal checks after the COVID-era continuous enrollment provision that let people stay enrolled without reapplying. That provision ended in March 2024, and ten months after that, only about half of those originally covered had been re-enrolled. Nationally, this resulted in a 10% drop in Medicaid enrollees.[1] The decrease, however, was far from even: Texas saw enrollment fall by about 20%, while California’s net enrollment decline was just 5.8%. 

There was a correlation between the size of the drop and whether a state had expanded Medicaid coverage under the Affordable Care Act or not. Non-expanded states tended to be more aggressive in pursuing Medicaid unwinding, but even within those states, the approach varied. According to another Kaiser Family Foundation analysis, a year after unwinding began, 17% of people in non-expansion states were uninsured, compared to just 8% in expansion states.[2] In other words, where you live plays a major role in whether losing Medicaid means getting other coverage or going without coverage entirely.

By 2025, the Gaps Are Clear

By mid-2025, the trend lines are hard to miss. In just two years, Texas lost 29% of its Medicaid-covered population from March 2023 to April 2025. During that same period, California saw only a 7% decrease. For EMS providers, that gap represents how many of your patients show up with coverage and how much of your run volume gets reimbursed.[3]

Major Unknowns

That statewide drop in Medicaid coverage shows up clearly in local EMS billing data. Here’s a snapshot from Digitech’s client agencies[4]: 

Texas – Medicaid

Municipality Type Effective Change
Large metro city -12%
Mid-size city -22%
Mid-size city -27%
Mid-size city -26%
Rapid-growth suburb -19%

Whether it’s a large metro system or a fast-growing suburb, agencies in Texas saw noticeable declines in Medicaid-covered patients between 2023 and 2024.

California – Medicaid

Municipality Type Effective Change
Large city -4%
Large county -2%
Medium county 8%
Mid-size city 5%
Rapid-growth suburb -7%
Mid-sized city 1%
Small town -13%

In California, the results were more mixed based on locality. For this set of agencies, the combined total Medicaid transports were down 4.5%. 

A small percentage of people who lost Medicaid nationwide did manage to get other coverage. About 4% obtained employer-sponsored insurance, 2% through the ACA Marketplace, and another 2% through Medicare[2].

Even so, Medicaid unwinding meant fewer patients with Medicaid in nearly every state, which put downward pressure on reimbursements for EMS agencies (and all healthcare providers). As the Texas-California comparison shows, the size of that drop, and the associated budget impact that follows, depends heavily on where your agency operates.

Enhanced Subsidies: Another Force in Play

At the same time Medicaid enrollment was dropping, another federal policy had a counterbalancing impact on the Medicaid reductions. The American Rescue Plan Act of 2021 (ARPA), later extended through the end of 2025 by the Inflation Reduction Act of 2022 (IRA), enhanced subsidies for ACA Marketplace plans, making them more affordable for millions of Americans.  

The result was a substantial increase in Marketplace enrollments. Per Kaiser Family Foundation, enrollment doubled nationally from 2021 to 2025.[5] That growth helped offset some of the Medicaid losses, though the impact varied by state.

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Just as we saw with Medicaid unwinding, the ACA enrollment surge did not hit every state the same way. From 2020 to 2025, Texas saw a huge jump with a 255% increase in Marketplace plan enrollment. California’s enrollment growth was smaller at 29%.[4]

Digitech’s client data again mostly validates this trend. In a sampling of Texas agencies, we saw strong growth rates in the commercially insured population as more residents moved onto ACA plans thanks to the expanded subsidies. 

Texas – Commercial Insurance

Municipality Type Effective Change
Large metro city 14%
Mid-size city 16%
Mid-size city 16%
Mid-size city 19%
Rapid-growth suburb 0%

California did not see the same uplift in insurance coverage per Digitech’s agency-level data.

California – Commercial Insurance

Municipality Type Effective Change
Large city 5%
Large county -2%
Medium county -5%
Mid-size city -6%
Rapid-growth suburb -9%
Mid-sized city -8%
Small town -1%

Why was this the case?  California had been aggressive in enrolling people within their state exchange, Covered California, prior to COVID and individuals who do not have healthcare coverage throughout the year are subject to a penalty on their tax return. The Texas gains for EMS agencies were strong, but not as much as the overall healthcare numbers. Digitech believes this is primarily due to the fact that EMS services skew toward the elderly and underinsured. That means macro changes in Commercial insurance coverage have a muted impact on EMS providers. 

Enhanced subsidies are a good example of a federal policy change that took years to roll out and gradually but steadily increased the number of people with coverage. Additionally, it highlights just how differently the same policy can play out from state to state and locality to locality.

What This Means for Your Agency

Federal and state policy changes have an impact on the number of insured patients in your community, but the effects usually play out over years, not months. Multiple initiatives, sometimes moving in opposite directions, make it difficult to isolate immediate impacts. 

OBBBA’s tighter Medicaid rules will push some off the program, mostly to the uninsured category. Because those changes are phased in over several years, the impact will be gradual and different in every state and every municipality. Meanwhile, the ACA subsidies are currently slated to lapse unless Congress takes action. If that occurs, enrollment in the marketplace exchanges is likely to drift downward, with more patients falling into the uninsured bucket. 

It will take a decade for Medicaid cuts under OBBBA to fully take effect, with the steepest reductions coming in years 5-10. Immediately after the bill passed, some of the lawmakers who supported it were already exploring ways to soften the impact of those cuts. And over the next nine years, political shifts are inevitable, making it nearly impossible to predict the exact long-term outcome. 

For now, Digitech expects EMS agencies to experience a gradual decline in reimbursements over the next few years related to recent federal legislative action/inaction. It won’t feel like a sudden budget crisis, but the trend is there and worth monitoring. The key is to treat these shifts the way you’d treat a patient’s vitals or your own smartwatch readout. Day to day, everything may look steady, yet the numbers may drift in ways that matter down the road. If you track them early and plan for the direction they’re heading, you’ll stay in control. If you assume stability, you risk being caught off guard by shifts that could affect staffing, equipment, or service levels. 

[1] Source: Kaiser Family Foundation. Three Questions About Medicaid Unwinding: What We Know and What to Expect by Robin Rudowitz, Jennifer Tolbert, and Larry Levitt. February 28, 2024 

[2] Source: A state-by-state comparison can be found in this analysis: Kaiser Family Foundation. KFF Survey of Medicaid Unwinding by Lunna Lopes, Grace Sparks, Marley Presiado, Jennifer Tolbert, Robin Rudowitz, Amaya Diana, and Ashley Kirzinger. April 12, 2024

[3] Source: Kaiser Family Foundation. Medicaid Enrollment and Unwinding Tracker. July 28, 2025 

[4] Data for both States represents more than 100,000 transports for agencies where comparable Digitech data existed for both 2023 and 2024. The Effective Change normalizes for changes in transport volume occurring at each agency.

[5] Source: Kaiser Family Foundation. Enrollment Growth in the ACA Marketplaces by Jared Ortaliza, Justin Lo, and Cynthia Cox. Apr 02, 2025

EMS in Unprecedented Times: Federal Funding Uncertainty in 2025 and Beyond

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Widespread layoffs. Looming budget cuts. Federal funding freezes. Tariff uncertainty. Behind the attention-grabbing headlines are critical questions from EMS agencies that need answers:

  • Will government payers continue to reimburse ambulance claims amid funding freezes?
  • How will federal cuts to Medicaid affect reimbursement?
  • Will Medicare payments take a hit?
  • Are Medicaid Supplemental Payment programs like GEMT at risk?
  • How can you navigate through tariffs?

The Rapidly Evolving Landscape

First, a Civics 101 lesson. Congress is the legislative branch of the federal government and holds the power of the purse, meaning it has authority over government spending. For substantial changes to occur, such as cuts in Medicaid or Medicare spending, Congress must pass legislation or budgets. Early signs in the current administration point to Congress creating a framework for sizeable spending cuts, but specifics are lacking at this point.

In the meantime, the Executive Branch has been issuing spending freezes through executive orders. There is no doubt that many government entities and individuals have been substantially impacted by those freezes, but major spending changes need to pass through Congress. Additionally, the courts have challenged many of these freezes, resulting in judicial orders for spending to continue.

At the time of this writing, the House budget resolution under consideration aims to cut at least $880 billion in costs over the next ten years. Experts say a substantial portion will need to come from Medicaid spending. Dissention is already rising; public sentiment indicates that not enough money is spent on Medicaid. According to a Kaiser Family Foundation Poll conducted February 14-19, only about 20% of respondents felt that too much was being spent on Medicaid and that it should be cut. Even among voters who supported Trump in the election, only 34% felt that too much was being spent on Medicaid. Around 19% of the U.S. population relies on Medicaid for health coverage[1], so Congresspersons’ constituents would be undoubtedly affected by cuts.

Medicaid is jointly funded by states and the federal government. Contributions vary state to state, but range from over 50% to 80%. What would happen if the federal government reduced its portion of the contribution? With roughly 19% of EMS patients covered by Medicaid in a time where Medicaid already under-reimburses providers for the costs of emergency ambulance transports, it’s not a stretch to say that EMS providers would be impacted.

States Backed Into a Corner

If federal Medicaid funding was reduced, the states would be put in a difficult situation. In the short term, states could cover the shortfall, but most are not in a financial position to do this for very long. Other options include reducing the amount reimbursed for services (e.g., announcing a 50% cut in reimbursement rates, which are already very low to start with for most Medicaid programs) or reducing the number of covered individuals. These options could start a domino effect of negative consequences for EMS providers, as the number of uninsured individuals would grow while the Medicaid-insured population would decline. Uninsured patients rarely pay their EMS bills in full (or at all).

Similarly, with Medicare, reduced payments are unlikely to occur quickly. Medicare add-on payments were just extended through the end of the federal fiscal year, leaving long-term and higher levels of extension uncertain. The budget extension has not addressed the longer-term, substantial cuts that Congress and the Presidential administration are considering. The 4% PAYGO sequestration[2], deferred for several years as part of funding the Infrastructure Recovery Act, is also up in the air.

And then there’s the Ground Data Ambulances Collection System (GADCS). The Medicare Payment Advisory Commission (MedPAC), tasked with advising Congress on Medicare issues, analyzed the initial dataset resulting from the GADCS that all EMS agencies were required to participate in. We were hopeful that the data and MedPAC’s final report, due in June 2026, would result in a substantive increase in Medicare allowance amounts for ambulance transports. But given the various staffing cuts and focus on spending reductions, it would not be surprising to see a delay or end to the current efforts to seek increased/fair reimbursements from Medicare.

It’s also unlikely that a consensus will be easily obtained on how to apply the recommendations that the Advisory Committee on Ground Ambulance and Patient Billing (GAPB) made regarding ground ambulance services vis-à-vis the federal No Surprises Act. With that said, addressing surprise medical bills is a topic that the current administration has said is a priority; hopefully that is not done without some thought and review of the GAPB report.

Major Unknowns

In addition to the various areas already covered, substantial changes to the global tariff structure appear to be likely. On the surface, EMS agencies are service providers and thus would not be substantially impacted by a change in the tariff structure. However, depending on how things play out, supply costs could rise depending on from where required items (ambulances, equipment, supplies) are sourced. Additionally, there are concerns that new tariff structures will cause inflation to rise, which would put pressure on agencies to increase wages, the largest expense item for EMS systems by far.

At this point, there are many more questions than answers. One thing that appears to be certain: uncertainty.

In this industry, we react to the unexpected. From 9/11 to the opioid epidemic to Covid-19, emergency responders have adapted and moved forward during plenty of “unprecedented times.” EMS providers will undoubtedly find ways to overcome any new challenge. But it shouldn’t have to be this way. We encourage all involved in the EMS industry to get involved:

  • Build relationships with local, state, and federal legislators. Regular meetings, phone calls, and emails can build strong working relationships, allowing EMS providers to educate them on the challenges faced by the EMS community and the need for improved funding. A good start is to write to your Congressional leaders and let them know how critical federal funds are for your organizations and communities.
  • Join established organizations and advocacy groups. This list of EMS Associations hosted by NHTSA’s Office of EMS (OEMS) shows organizations with which the OEMS collaborates most frequently, giving them a voice on the federal level. A unified voice has more impact when lobbying for legislative changes.
  • Utilize digital and media outreach. EMS professionals can use social media platforms to raise awareness about funding issues, or even work with local news outlets highlight the challenges of EMS underfunding. Op-eds and opinion pieces for local newspapers or online publications can also have impact. Bringing public attention to the issues can pressure lawmakers to act.

Even small efforts and actions can make a big difference. EMS personnel and their supporters have the power to advocate for both preservation of and increases in reimbursement and funding, paving the way for more sustainable, efficient, and effective emergency medical services.

[1] Source: US Census Bureau, Health Insurance Coverage in the United States: 2023, September 2024.

[2] The 5% PAYGO sequestration refers to a mandatory spending reduction triggered by the PAYGO (Pay-As-You-Go) rules, which require offsets for new federal spending. For several years, this sequestration was deferred to support funding for the Infrastructure Recovery Act. For EMS, this sequestration could potentially reduce Medicare payments to providers, impacting their funding. However, the deferral allowed EMS services along with other federally funded services to avoid these reductions during the period when the infrastructure act was funded.