North Dakota Ambulance Services Face Severe Financial Challenges

Study finds average loss of nearly $500 per patient transported due to unpaid claims and other funding issues

Published on Feb. 27, 2026

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A recent survey of North Dakota's ambulance services revealed they are facing significant financial challenges, with an average loss of nearly $500 per patient transported. The study, conducted by consulting firm PWW Advisory Group, found that uncollected claims are a major cause of financial stress, with an estimated $5.8 million in unpaid ambulance claims in 2025. The survey also highlighted issues with workforce retention, capital costs, and lack of reimbursement for treatment without transport.

Why it matters

The financial struggles of North Dakota's ambulance services have serious implications for public safety and access to emergency medical care, especially in rural areas. Without adequate funding, services may be forced to cut staff, equipment, or even shut down entirely, putting communities at risk. Addressing these issues is crucial to ensuring reliable and sustainable ambulance services across the state.

The details

The survey, which garnered responses from 36 of the state's over 100 ambulance services, found that on average 78.7% of ambulance claims were paid, with the average claim sent to collections being $1,063. Consultants extrapolated that there was $5.8 million in unpaid ambulance claims in 2025. The survey also showed an average ambulance service attrition rate of 12.7%, with employees citing inadequate pay and limited benefits as the main reasons for leaving. Additionally, the survey found that roughly 17% of calls resulted in treatment without transport, but only half of services billed for those non-transport calls. Capital costs for equipment and vehicle replacement were also identified as a significant, unavoidable, and underfunded issue.

  • The survey was conducted as part of House Bill 1322 during the 2025 legislative session.

The players

PWW Advisory Group

A Pennsylvania-based EMS consulting company that conducted the survey and presented the findings to the North Dakota Legislature's interim Emergency Response Services Committee.

Matt Zavadsky

A consultant with PWW Advisory Group who presented the survey findings.

Steve Wirth

A consultant with PWW Advisory Group who presented the survey findings.

Todd Porter

A Republican state representative from Mandan, North Dakota, who is a paramedic and the owner of Metro-Area Ambulance Service.

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What they’re saying

“We explain this to policymakers all the time. 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.”

— Matt Zavadsky, Consultant, PWW Advisory Group (The Bismarck Tribune)

“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.”

— Todd Porter, State Representative, Paramedic, and Owner of Metro-Area Ambulance Service (The Bismarck Tribune)

“If you were going to fix something, fixing the federal system would be a really good starting point. Everything else that we're doing and trying to do, from a state standpoint, is because of the lack of response from Medicare.”

— Todd Porter, State Representative, Paramedic, and Owner of Metro-Area Ambulance Service (The Bismarck Tribune)

What’s next

The North Dakota Legislature's interim Emergency Response Services Committee will likely use the findings of this survey to inform future policy decisions and funding allocations to support the state's struggling ambulance services.

The takeaway

The financial challenges facing North Dakota's ambulance services, including unpaid claims, underfunded capital costs, and workforce retention issues, pose a serious threat to the availability and reliability of emergency medical care across the state. Addressing these systemic problems will require a multi-faceted approach involving state-level policy changes, increased funding, and innovative solutions to ensure all communities have access to the critical services ambulances provide.