Sick or injured Missouri residents who need air ambulance services face thousands of dollars in bills and sometimes aggressive collection efforts if they cannot pay, according to a state report.

The average bill after insurance for people who needed air ambulances in 2017 was $20,000, the Missouri Department of Insurance, Financial Institutions and Professional Registration said in a report issued Tuesday.

The report found one patient who was billed $25,000 after getting kicked by a horse and another billed $100,000 after being transferred out of state for treatment of encephalitis, KCUR reported .

Air ambulance companies billed Missouri residents nearly $26 million for services in 2017, leaving patients responsible for $12.4 million after coinsurance, copays and deductibles. That is about $20,000 per individual, said Angela Nelson, director of market regulation at the insurance department and leader of the team that produced the report.

"That's kind of a jaw dropper to us in terms of how much we're talking about," Nelson said.

The report found that insurance companies can't negotiate prices with many air ambulance services because they are not "in-network" providers.

It also found many air ambulance companies use collection practices such as placing liens on homes or garnishing wages if patients are unable to pay the bills. Nelson's team found 184 Missouri court records since 2012 involving lawsuits by air ambulance companies, with most collection actions.

Medicare reimbursement rates for air ambulance services range between $3,368 and $6,404 and Medicaid reimbursements average $2,253. In contrast, private health insurers were billed an average of $41,321, of which they paid an average amount of $23,087, according to the report.

A statement from the Association of Critical Air Transport, comprised of air and ground ambulance providers, said the group was concerned about the exorbitant bills. The group supports federal legislation to improve consumer protections for air ambulance patients and to amend the Airline Deregulation Act so states are allowed to regulate air ambulance prices.

Air ambulance companies say their prices are dictated by high fixed costs and the need to offset low reimbursement rates from Medicare and Medicaid. A U.S. Government Accountability Office report in 2017 found one company said operating a single air ambulance helicopter requires a staff of 13 - four pilots, four nurses, four paramedics and a mechanic - in order to maintain the ability to deploy at any time.

The report also noted that air ambulance providers are not subject to the price competition because patients have no say in how and by whom they're transported and can't avoid out-of-network providers.

Nelson said her agency can't do much to lower prices other than respond to consumer complaints. Since 2013, it has received 128 complaints or questions about air ambulance services, she said, and in 23 cases the department helped recover a total of $560,000.