By Grant Coursey
The Bismarck Tribune, N.D.
BISMARCK, N.D. — A recent survey of North Dakota’s ambulance services showed an average loss of nearly $500 per patient transported in the state.
In a Wednesday presentation to the Legislature’s interim Emergency Response Services Committee, representatives of PWW Advisory Group — a Pennsylvania -based EMS consulting company — explained that the state’s ambulance services are facing significant fiscal challenges based on a recent study of delinquent billing reimbursement.
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Specifically, the consulting group said uncollected claims are a major cause of financial stress for ambulance services.
The study was created as part of House Bill 1322 during the 2025 legislative session. The consultant group put out a survey to North Dakota ambulance agencies, garnering 36 respondents of more than 100 ambulance services in the state — a lower response rate than consultants Matt Zavadsky and Steve Wirth said they would have liked but still enough to draw conclusions from.
The respondents were a diverse mix of city and county ambulance services, district-owned services, hospital-based services and private services across rural and urban areas of the state.
Of the services that responded to the survey, 78.7% of ambulance claims were paid, and consultants said the average claim amount sent to collections in 2025 was $1,063.
The consulting group extrapolated from survey responses that there was $5.8 million in unpaid ambulance claims in 2025.
“We explain this to policymakers all the time,” Zavadsky said. “Suppose you walk into Dunkin’ Donuts and you say, ‘Hey, I would like a cup of coffee, but I’m not going to pay for it.’ In this particular case, if 20% of the customers going into Dunkin’ Donuts said, ‘I’m not paying for the coffee’ ... That places a significant financial burden on the organization.”
He explained that this shortfall in funding can lead to other problems such as lower pay resulting in workforce shortages because ambulance services simply don’t have the money to pay more.
One suggestion from the consultant company was to have North Dakota reimburse ambulance services for the unpaid claims at a state Medicaid rate, which would cost roughly $4.8 million.
The survey showed that North Dakota ambulance services are experiencing an average attrition rate of 12.7%. Most of the employees leaving cite inadequate pay and limited benefits as the reason they choose to leave.
Rep. Todd Porter, R- Mandan — a paramedic and the owner of Metro-Area Ambulance Service — said recruitment and retention is the biggest area of concern for him. He said it is important to support local career and technical centers to start teaching the necessary skills for people to go into EMS jobs, and to put glamour back into the jobs to generate pride in the work and interest in the job from a young age.
“The TV shows ‘Emergency!’ and ‘Rescue 911' — those shows that put glamour into the job, where kids were watching that program and they were going, ‘Hey, that’s what I want to do.’ We need that, and we need people to want to be interested in doing these very essential jobs back in our communities,” Porter said.
Consultants also explained that the ambulance services are typically only reimbursed if they transport a patient and are losing money by providing treatment without transport in the state. The survey found that roughly 17% of calls resulted in treatment without transport.
Porter said the state does have a law that allows ambulance services to bill for treatment that does not involve transporting a patient; he introduced the bill that created it over 15 years ago. He said North Dakota Medicaid and most private medical insurance services will reimburse patients for bills on treatment without transport, but Medicare will not, and Medicare calls make up 60% of treatment-without-transport calls.
He also said Medicare reimburses ambulance services at a considerably lower rate than North Dakota Medicaid or private services do.
“If you were going to fix something, fixing the federal system would be a really good starting point,” Porter said. “Everything else that we’re doing and trying to do, from a state standpoint, is because of the lack of response from Medicare.”
The survey showed that only half of surveyed ambulance services billed for non-transport calls.
The last major finding from the survey was that capital costs — the cost of upkeep and replacement of equipment and vehicles — are significant, unavoidable and underfunded.
The survey showed that the average planned capital investment per agency over the next five years of agencies that responded to the survey was $357,667, a total of $12.9 million across the 36 responding ambulance services.
Consultants cautioned that without predictable capital support, agencies could face equipment failure, safety risk and service interruption.
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