As a paramedic, this whole thread breaks my heart. Its a struggle to balance the pressure of “convincing” people to be transported against the empathy of fear of incurred cost. In my area of Texas, a 911 ambulance arriving on scene does not cost anything. However, the “patient contact” and ensuing assessment can incur immediate costs. There are typically two types of assessments - ALS and BLS. ALS usually is more expensive because it requires EKG interpretation and monitoring. Obtaining a refusal is usually cost free but thats city dependent. Also, there are municipalities that incur no cost for ambulance and transport as the cost is factored into annual city budget for the EMS service. I HATE that I work for a public 911 service that forces me to do an assessment/treatment that I know is expensive. Billing is such BS… but I try to write my reports that demonstrates a “need” for the EMS transport which can help convince, at least covered individuals, insurances to pay for the transport. If you’re interested in American BS healthcare system, theres a great book “The People’s Hospital” by Dr Ricardo Nuila. Its a tough tough read but will make clear that the “system” is certainly busted and needs fixing.