AUGUSTA — If someone breaks a leg or has a heart attack, their ability to pay for an ambulance ride is among the least of anyone’s concerns in the heat of the moment.

But when the ambulance service providing transport is facing nearly $2 million in debt from patients either unable or unwilling to pay their bills and the money to pay that debt would come from taxpayers, it’s concerning for policymakers.  That’s the case in Augusta, where city officials are now considering for the first time sending those debtors to a collection agency to try to recover at least some of those funds to help offset the costs.

But not everyone agrees. Some city councilors, who have been debating the issue, are concerned doing so could leave patients who took that ambulance ride to the hospital with a bad credit rating, which could in turn affect their ability to finance a home or car.

Across central Maine, most other ambulance services, both municipal and privately run, already send their uncollected bills to a collection agency after normal billing efforts fail to secure payment, including Waterville, Winthrop, Delta Ambulance, which serves numerous area towns, and Gardiner.

In Augusta, Deputy Fire Chief Steve Leach said over the last two years $1.8 million in bad debt has accumulated from patients’ unpaid bills. The city does not currently send unpaid ambulance bills to collections. City councilors are considering it for the first time, and Leach recommends doing so, despite data that suggests collection efforts won’t bring in anywhere near what’s owed.

Leach said most of the unpaid bills are from people without insurance who pay out of pocket, with only 1.3% of the total amount billed to them being paid, for a total over the last 12 months of $663,000. Patients with private insurance have tallied $576,000 in unpaid bills in the same period from failing to pay their share through co-pays.

Leach said the city’s billing company estimates about 10% of that bad debt could be secured through a collection agency. The collection agency would charge a fee of 20% of the amount it collects. Out of the more than $1.8 million in debt, the city may get only about $146,000.

Some councilors said it’s worth the effort to go after that money, because otherwise, taxpayers are left to cover the cost of those who don’t pay.

“If we can collect one more dollar, that’s one more dollar than we have, so I just think it’s an absolute slam dunk,” Ward 3 Councilor Mike Michaud said during a recent Augusta City Council debate of the issue.

Other councilors said sending bills to collections could result in residents unable to pay their bills getting a bad credit rating, something that could negatively affect their lives in many ways. Some patients might even decide to not take an ambulance to the hospital even if they’re suffering a medical condition, out of fear they can’t afford it, they said.

“My first thought was yes, we need to send this to collections, it’s money,” At-Large Councilor Annalee Morris-Polley, said. “But then I started thinking about $146,000, and started thinking about how many Augusta residents are we talking about that are middle class, working, they’re barely making it by, are paying taxes in Augusta. And now, based on having an accident or something medical going on, now they’re being brought to the hospital and they have a $1,200 co-pay. And they don’t make that payment and then their credit is hit, and that credit impacts their ability to rent, to buy a car, to really function.”

Cities and towns take different approaches to collecting the fees owed them for ambulance transports.

In Gardiner, the municipal fire department-based ambulance service serves Gardiner and neighboring towns that contract with it for ambulance services — Pittston, West Gardiner, Farmingdale, Randolph, Litchfield, Richmond, and half of Chelsea. It’s run as an enterprise fund, which means that its costs are paid by people who use the service.

Gardiner’s billing company tries to collect payment from patients for about six months. If the bill isn’t paid, or a payment arrangement isn’t made by then, the bill is sent to collections. Fire Chief Rick Sieberg said the ambulance service has been doing that for as long as he recalls, at least 20 years.

Sieberg said Gardiner typically has about $200,000 a year in bills that don’t get paid by patients or their insurance providers. Some don’t have any insurance, while others have insurance that still leaves them with substantial deductibles or co-pays to pay themselves.

Sieberg said the collection rate on bills going to collections is pretty low, and eventually, the service must write off that bad debt as uncollectible.

Gardiner sends the unpaid bills of residents of the towns it serves to those member towns, billing them for the unpaid amount.

Winthrop Ambulance Service responds to Fayette, Wayne, Manchester, Monmouth, Mount Vernon, Winthrop and Readfield. For the first time in the upcoming fiscal year, it is following Gardiner’s model of charging its member towns for the cost of unpaid bills for ambulance services provided to residents. Winthrop, which previously covered the approximately $100,000 a year in unpaid bill costs itself, is charging those communities a percentage of the total, based on the use of ambulance service by residents of those communities over the last three years, according to Anthony Wilson, town manager.

Nick Henderson, interim chief of Winthrop Ambulance Service, said its billing company sends unpaid bills to collections after 90 days. After six months, if payment hasn’t been secured, the debt is written off as uncollectible.

Delta Ambulance, based in Waterville and running on a roughly $8 million annual budget, averages about $600,000 a year in unpaid bills going to collections. Executive Director Chris Mitchell said that brings in only about $12,000 in payments a year. The private ambulance service that serves Albion, Belgrade, China, Vassalboro, Sidney, Whitefield, Windsor, Somerville, Fairfield, Benton, Oakland, Smithfield and Rome sends bills out with 30-, 60-, and 90-day notices. If no payment has been made or arranged after 150 days, it sends those bills to collections.

Ambulance services across central Maine and elsewhere are also facing other financial pressures. They provide services that often cost well over what private insurance companies or Medicare and Medicaid will pay for their customers who receive those services. Uncollected bills only add to the strain.

“We try to work with patients to avoid getting to that point,” Mitchell said. “It’s an incredible financial strain. Especially since, even if we’re getting paid, the reimbursement doesn’t cover the costs anyway.”

Waterville’s city’s ambulance service sends unpaid bills to a collection agency after 120 days but, Fire Chief Jason Frost said, it does not send the unpaid bills of Waterville residents to collections, only those of out-of-town patients.

Since July 2022, Frost said, when the city started the ambulance transport service, it has amassed about $500,000 in unpaid bills.

He said Empire Collections, the agency Waterville recently began using, estimates it collects about 30% of the unpaid bills they pursue.

Clinton Ambulance Service, like Augusta, is among the few Maine ambulance providers not sending its unpaid patient bills to collections.

Clinton Fire Chief Rick Barton said the service bills about $350,000 a year. About 40% of that goes unpaid and is written off at the end of the year.

State and federal policymakers have considered easing the burden of ambulance debt by keeping unpaid ambulance bills from affecting consumer credit.

A bill pending before the state Legislature, An Act to Strengthen Consumer Protections by Prohibiting the Report of Medical Debt on Consumer Reports, would prohibit consumer reporting agencies from reporting debt from medical expenses on someone’s credit report. The Health Coverage, Insurance, and Financial Services Committee voted “ought to pass” on LD 558 earlier this year, but no action was taken and the bill was carried over to the next legislative session.

At the federal level, a Consumer Financial Protection Bureau medical debt rule proposed under the Biden administration would ban medical debt from going on credit reports. It was scheduled to take effect in March, but it has been delayed until June. Under the current Trump administration, the Consumer Financial Protection Bureau is now seeking to vacate that rule.

In Augusta, no decision has been made. Leach is gathering more information for city councilors and will report back to them before they decide what action they will take.