In the U.S. the insurance companies pay the transport fee primarily. The fall back to that is billing the individual for the service. We never check to see if the victim has insurance before pick up.
We have a fairly complex dispatch thread but the short of it is that the first responders (ground ambulance and fire units) are the ones to request us.
This means that a scene call close to an appropriate hospital (trauma level hospital) will most likely not be worked by an aircraft. The business end of this has evolved towards that end.
Likewise the trend is towards the air company handling the medical staff in house and the billing. This is still very much in evolution but for billing alone, having dedicated specialists that know all the ins and outs of the billing nightmare pays for itself many times over.
If the subsidies are going away look towards the providers that copy a proven method of doing it for job security.
Fly safe !
