> So while dying of a heart attack he should have been negotiating with the ambulance driver, the paramedics, the nurses, each intern and doctor to make sure they are "in-network".

Absolutely! </s> I work in EMS. Thankfully, our Medic One system is funded entirely by property taxes and we simply do not bill (at all) for any treatment or transport.

However, a few years ago United got a lot of grief over denying airlift transport claims from things like MVAs, or traumas in remote locations, stating that the "transport had not been pre-approved through the insurer".

Apparently in their mind, us paramedics (or maybe the chopper pilot) should have been calling in between stabilizing our patient...

"This is John, I'm a paramedic working on one of your patients who was hit by a truck. We would like to fly him to the hospital due to his extensive multisystem trauma but we need your approval. His name? Hang on, let me find his wallet. No, that's Smythe, S-M-Y-T-H-E, sorry, it's a bit loud with the jaws of life in the background... Yes, I can hold for a nurse consult..."