Considerations in the development of a structured approach to establish costs and charges and to improve reimbursement for an air ambulance provider are discussed in relation to current and future trends in the air medical industry. Special structures must be put in place to ensure that the unique characteristics of an air medical program are addressed and that the program does not become a financial burden on its sponsoring institution(s). Emphasis is placed on the need to determine the accurate cost of providing services to establish appropriate charges and for negotiations with prospective payers. Relationships between air ambulance services and their sponsors will require careful evaluation for both parties to position themselves appropriately for the future.