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In May 2007, the United States Government Accountability Office (GAO) released a report entitled Ambulance Providers: Costs and Expected Medicare Margins Vary Greatly. The report assesses the differences between payments and costs, referred to as "Medicare margins," in urban (areas within a metro statistical area), rural (areas outside of a metro statistical area), and super-rural (areas in the bottom 25% of rural areas in population density) regions, and the reasons why these three assessments differ in each geographical area. The NVFC was one of many associations representing the emergency medical services that helped to develop the document, and one of five associations that were asked to review and comment on it before release.

In 2002, Medicare began phasing in a national fee schedule to allow for the standardization of payments for ambulance services. The following year, Congress enacted the Medicare Prescription Drug, Improvement, and Modernization Act (MMA) which implemented a regional fee schedule that overlapped with the transition to the national fee schedule. The report covers the Medicare margins that derive from MMA.

The report does not include an examination of "shared services" providers, like fire departments delivering EMS, because the GAO assessed that in general, shared services providers are not able to reliably isolate their ambulance costs from other costs. The GAO did note that it has no basis or information to suggest that providers with shared services have higher or lower costs than other providers.

After considering forecasted Medicare margins, transport costs after the enactment of the MMA, and characteristics contributing to differences in costs, the GAO found that a shift to a national fee schedule may work to raise costs and cause negative Medicare margins (costs will be greater than payments received) in super-rural areas that are generally served by volunteer fire and EMS agencies. For this reason, the GAO recommended that the adequacy of Medicare payments to ambulance providers be monitored in order to combat inadequate ambulance service in super-rural areas due to high costs and negative Medicare margins.