QMC Ambulance Billing Services

OIG Reports on Overpayments Sparks Discussion

2018-07-27T09:38:00.000-04:00

This Month

The Office of the Inspector General made public the report “Medicare Improperly Paid Providers for Non-Emergency Ambulance Transports to Destinations Not Covered by Medicare” (https://oig.hhs.gov/oas/reports/region9/91703018.pdf) this month.

The OIG took a look at non-emergency ambulance transport claims paid by Medicare between 2014 and 2016. This time the review focused on transports to what the Centers for Medicare and Medicaid Services labels non-covered destinations. Specifically, the transport codes for ALS and BLS non-emergency along with the accompanying ground mileage codes were dissected.

Over $8 million!

The study concluded by disclosing that a total of $8,633,940 was improperly paid on claims amounting to 62,642 claim item lines.

Over half of the claims that were paid improperly where transports to diagnostic or therapeutic sites other than a hospital or physician’s office and that did not originate at a skilled nursing facility (SNF). An additional one-third were paid improperly for transports to residences or assisted living facilities that did not meet the origin/destination rules.

Modifier Review

When billing ambulance transports, assuring the origin and destination modifiers are correctly applied is an absolute must to avoid submitting errant claims for payment. Since we all use computer programs to bill, it is always a risk when entering a facility into the system that the applied modifier that identifies the facility could be coded incorrectly and then populated throughout all future claims.

One simple error when entering the facility either by true human error or lack of research and control of the process for entering a facility could magnify the systems error across hundreds if not thousands of claims.

Research and Know

It is important to research and know the exact purpose of the facility when entering and applying the origin/destination modifier that will generate when picking the facility for the claim.

As a reminder, the origin/destination modifiers for use are…

D- Diagnostic or therapeutic site (not a doctor’s office or hospital)
E- Residential, domiciliary, custodial facility, nursing other than a Skilled Nursing Facility
G- Hospital based dialysis facility
H- Hospital
I – Site of Transfer (e.g. airport, ferry, helicopter pad) between modes of ambulance transport
J- Non-Hospital based dialysis facility
N- Skilled Nursing Facility (SNF)
P- Physician’s Office/Clinic
R- Residence S- Scene of Accident or Acute Event
X- Destination Code Only (Intermediate stop at a physician’s office en route to a hospital to stabilize a patient)

The tricky part about applying these necessary modifiers comes when it’s not clear what the origin and destination are.

Consider the Possibilities

Multi-purpose facilities have been built today to accommodate a wide range of residents. It’s not uncommon to have one facility at one central address contain separate parts with varying housing types.

XYZ Living Campus may have a SNF wing, another area that is designated as assisted living and yet a third part, on the same physical grounds and with the same address, that is an independent living area for senior residents.

Here again, properly identifying these various functions in the billing software set-up is important, but even more important is for the transport crews on the street to document specifically where they picked-up and dropped-off the patient.

The same principle applies to hospitals with various dedicated floors for multiple purposes. Even doctor’s offices can be housed within a facility requiring a separate origin/destination modifier versus the inpatient area which requires yet another.

These are just some of many possible examples.

What’s Next

The OIG report chided CMS for not requiring the Medicare Administrative Contractors (MACs) to implement nationwide prepayment edits in their systems to filter out and disallow payments for non-emergency ambulance transports to destinations not covered by Medicare.

So, that will change.

Secondly, the OIG charged CMS to recover the portion that is still recoverable of the $8.6 million dollars in improper payments identified in the report. It also charged CMS to instruct the MACs to notify ambulance providers and suppliers of improper payments made to them that are outside of the re-opening period so they can exercise their “reasonable diligence to investigate and return any identified improper payments in accordance with the existing 60-day rule for returning payments.

Additionally, the OIG strongly recommended that CMS direct the MACs to review claims for non-emergency transports that followed the 4-year audit study period and recover any improper payments identified.

Beware!

Now’s the time to review your systems and processes, especially as it relates to origin and destination modifiers and their application. Of course, assuring that you are using a reputable third-party billing contractor who has the appropriate knowledge and controls in place to prevent mis-application of these modifiers is always the best course of action.

Take Compliance Seriously- Or…It Will Cost You!

2018-07-13T10:09:00.000-04:00

In the News

Recently, some scary EMS articles have been published. Here are some headlines…

Fla. Ambulance company to pay 1.2M in federal whistle-blower lawsuit

<Company name redacted> settles Medicare fraud suite for 12.7M

Ambulance company owner sentenced to prison for fraud

Feds crack down on Medicare ambulance fraud

Get the Picture?

Do you get it?

Everyone connected with Emergency Medical Services in America needs to sit up and take notice. If you are swimming in the murky waters of ignoring compliance issues, then you are about to be gobbled up by the hidden shark in those waters.

And…the bite you are about to receive is going to hurt, badly.

None of us who live in this world of all things EMS, especially in the ambulance billing world can ignore how important maintaining strict compliance guidelines is for us. For a long time, there have been those in our industry who thought they were getting away with bilking the entitlement programs out of millions of dollars by “juicing up” documentation, resulting in claims submitted to Medicare, Medicaid and even commercial insurance plans that were anything but compliant.

It’s the end of the road for them.

Wake-Up Call

One of the biggest wake-up calls was the inception of the Medicare Prior Authorization for Repetitive, Scheduled Transportation Demonstration Program.

On Day One of the inception of this trial program, the areas covered by the demonstration- those geographic areas showing the highest over-utilization statistics- saw a drastic decrease in the reimbursement dollars flowing from Medicare.

Of course, we all saw whole ambulance companies padlock their doors and certainly there was quite a debate regarding the program and the impact on access for patients in some rural areas given the loss of services. Yet, now that the dust has settled in the demonstration program States, it seems like life has found a new normal and the chance for those ambulance operators who were operating under-the-radar committing widespread abuse of the system has diminished greatly.

Much to the delight of the Feds, the program worked as intended spotlighting activity that was detrimental to the Medicare system as a whole.

What to do?

So, you’re an ambulance company’s administrator and you read all of the articles and suddenly you have this strange feeling in the pit of your stomach…what do do?

Are we safe? Is my company following all of the rules? How can I be sure?

Relax…there are ways to ensure that you’re coloring between the lines.

Get Help!

First off, there are experts out there that can help you.

Get help!

No one of us can be experts in everything we do. There are those who specialize in all things compliance. Find them…engage them…work with them. Find a partner to help you review and audit all things billing and compliance related. Seek out those individuals and/or companies who can help you be compliant.

The days of going it alone in this business are far gone. You cannot take chances, especially if your run volume is of any size. One repeated mistake in billing can be multiplied over hundreds of claims. If undiscovered, by the time you identify that you have a problem many dollars may have flowed to you from Medicare, Medicaid and/or insurances that you are now liable to re-pay in order to keep you out of trouble.

Compliance is not a one-time thing. It must be a living, breathing, on-going dynamic part of your everyday EMS life just like everything else you do daily be it in the field or in the office.

Consider Outsourcing

Okay, so maybe Mabel has been your “billing person” since 1980-something and you love her to death.

We understand.

But, have you been able to keep Mabel up-to-date on the latest and greatest in EMS billing and compliance? Quite frankly, do you even have a written compliance program backed up by continual audits and monitoring? Or is your compliance program simply a binder with a foot of dust on it, somewhere to the far corner of your office shelf?

Is Mabel a certified coder? Has she been keeping up on the new rules and regulations or have you just not had the time and money to help her achieve your compliance goals?

An outsourcing company, like our company here at Quick Med Claims, can help!

You can be assured that our company has, not only the certified people, but also the processes and procedures in place to closely monitor your compliance- submitting each and every claim in compliant fashion.

Is it time to consider outsourcing?

If your answer is “Yes” then avoid becoming the next headline and contact our office today.

Then tonight…rest easy. We got this!

Ambulance Industry Legislation Update

2018-06-29T10:22:00.000-04:00

In this space…

Over a few month we reported in this space about legislation in several States that had the potential to impact the ambulance industry in a big way.

Since those posts, there have been some positive developments on a few fronts.

Pennsylvania Legislation Passes

The new State budget passed with little fanfare in the Commonwealth of Pennsylvania. Dubbed House Bill 2121, the bill passed easily in a State where budget bills often cause heated discussion and prolonged passage delays.

The new budget incorporates the provisions of the aforementioned House Bill 699 ushering in a 50% increase in Medicaid reimbursement for the first time since 2004. The increase will take effect January 1, 2019.

Basic Life Support transports will now be paid at a base rate of $180 per transport, up from the previous $120. Payment for transporting at the Advanced Life Support level will increase from $200 per transport to $300.

New York Legislation Push Advances

While legislation allowing fire-based EMS to bill and collect reimbursement in the State of New York has yet to pass, the word circulating at Fire 2018, the annual New York State Association of Fire Chiefs (NYSAFC) conference, is that there has been headway made in talks to advance the legislation in the Empire State.

As we reported previously, New York statute prohibits fire-based EMS from billing. The NYSAFC and others are strongly pushing for this moratorium to be lifted, allowing fire departments with an EMS component to bill for their services. Citing a growing number of fire departments mothballing EMS, with negative effect on smaller, remote communities noticeable; the legislation is being championed as a “rescue effort” for EMS in those community fire departments.

Word from the floor at convention headquarters in Verona, New York, is that discussion between the NYSAFC and State lawmakers is advancing with compromise verbiage being discussed on some of the finer points of the final language in the bills (Assembly and Senate.)

CMS Holds Data Collection System Listening Session

This week, the Centers for Medicare and Medicaid Services (CMS) hosted an audioconference listening session as the first step in response to Congress passing the Bipartisan Budget Act (BBA) of 2018.

You’ll recall that Section 50203 of the BBA of 2018, brought an extension of the Medicare ambulance add-on payments through 2022. However, with that extension comes the Congressional mandate for CMS to begin the process of developing a method for collecting cost data from the industry.

The statute calls for Ground Ambulance Providers and Suppliers to submit information detailing their costs. CMS must collect cost, revenue, utilization and other information determined appropriate by the Secretary of Health and Human Services (HHS) and submit the report to Congress. The Act mandates CMS to specify the data collection system that will be used and who must report by no later than December 31, 2019.

The listening session was meant to gather on-the-record testimony from industry stakeholders regarding their thoughts on what data is to be collected and the method for collecting it. While CMS is not bound to follow these recommendations, it was well-received by those participating that CMS opened the door for input from the industry up front and prior to making a final decision on the cost data collection process.

Synopsis of Comments

Numerous comments were entertained during the listening session call. Some of the most notable included these suggestions.

Nearly all those who commented applauded the announced CMS decision to not use the existing hospital cost reporting mechanism. Those commenting agreed that the hospital data collection process would not serve the ambulance industry adequately for this mandate.

One commenter asked CMS to insure to have a mechanism in place to filter out the non-cost of volunteer labor. The commenter asked for a data collection floor of a minimum of two full-time employees to be the benchmark so to not negatively skew cost data collection results by including all- or mostly-volunteer staffed EMS agencies with zero labor costs.

It was requested that CMS gather cost data that includes the costs for EMS to treat patients who do not require transport.

One caller asked CMS to consider, in their final analysis, how the Medicare Fee Schedule not only impacts the American ambulance industry directly through Medicare program reimbursements, but also to take into account how many commercial payer sources base their ambulance reimbursements fee schedules on the National Medicare Ambulance Fee Schedule.

There was a request for CMS to devise a means to factor in local government-based EMS department costs which the commenter explained are subsidized by tax dollars, potentially affecting the cost picture for those entities. The concern by this caller was that local tax dollar supported EMS providers would potentially lower the final cost report due to those locally-collected subsidies.

Legislative Initiatives Poised to Benefit EMS in Three States

2018-06-08T12:17:00.000-04:00

PA, NY and MD

State lawmakers in Pennsylvania, New York and Maryland have been working on new legislation that has the potential to drastically change the EMS reimbursement landscape.

This year has seen a flurry of activity in the chambers of government across these States as fire and EMS advocates are sounding the alarm regarding stagnant reimbursement rates that are failing to keep pace with the growing costs to provide EMS services.

While Pennsylvania and New York lawmakers are still considering future passage of their initiatives, their counterparts in Maryland have successfully pushed legislation that has now been signed into law by that States governor.

Maryland Senate Bill 682

On May 15th, Governor Larry Hogan signed into law Senate Bill 682. The new law will be enacted officially on July 1st.

This new law charges the Maryland Institute of Emergency Medical Services Systems (MIEMMS) and the Maryland Health Insurance Committee to initiate a 6-month study for report back to the State Legislature to devise a plan that will require commercial insurance payers and Maryland Medical Assistance to pay for the following…

Mobile Integrated Health Care (MIHC)
Treatment of a patient on the scene but with no transport required
Transport of a patient to an alternative location that is not a hospital destination

The bill calls for a comprehensive plan to be submitted as part of the report including a plan for how such reimbursement will be obtained from the Medicare program, as well.

Under consideration, as part of the study, is for the Maryland Medical Assistance program to initiate a rule change so Medicaid payments can begin on January 1st. The Medicare issue, while tied up in Federal initiatives may be tackled under a waiver program set to take effect also on January 1, 2019 which includes a “total cost of care” initiative.

Pennsylvania Senate Bill 1013 / House Bill 699

Legislation spearheaded in Pennsylvania by a State lawmaker with direct EMS ties has been passed just this week in the Pennsylvania Senate. Senate Bill 1013 was approved by the upper chamber, putting into motion a series of events that will require Pennsylvania Medicaid and commercial insurers to reimburse EMS agencies when emergency treatment is provided at the scene but transportation is not required.

State Representative Martin Causer of the 67th Legislative District encompassing Potter and McKean Counties in the Bradford and Coudersport areas of the State is leading the rally complete with House Bill 699. Causer, a former EMS provider himself, has been a champion for this legislation. This week he organized a rally of EMS representatives in Harrisburg which later resulted in the passage of SB 1013.

HB 699 takes another pathway to improving reimbursements for Pennsylvania’s ambulance industry. The bill proposes a 50% increase in Pennsylvania Medicaid reimbursements, which would be only the second such fee update since Medicaid began reimbursing for ambulance transportation in Pennsylvania.

As the overall discussion of the thinning ranks of fire and EMS personnel in Pennsylvania gains traction, these initiatives at the State government level will help ease some of the concerns for EMS administrators across the Commonwealth.

New York S0363 / A7717b

With a heavy push by the Fireman’s Association of the State of New York, the New York State Association of Fire Chiefs and the County Fire Coordinators Association of the State of New York, two bills have been introduced that are mirrored in nature. In the Senate S0363 and in the Assembly A7717b were introduced earlier this year with focus on allowing Fire Departments in that State to recover the costs of EMS services.

The move has gained traction as championed by several North Country lawmakers who growingly have become concerned regarding fire departments in that geographic corner of New York expressing concern over growing budget shortfalls when providing ambulance services.

New York State has always had a moratorium in place prohibiting recovering reimbursement for EMS services by fire departments. For perspective, consider that of the 1,025 ambulance services in New York State, 468 of them are fire-department based accounting for 300,000 calls for service each year.*

The legislation has gained considerable headway over the past several weeks with the Senate moving S0363 into both the Local Government and Finance Committees while the State Assembly has Advanced A7717b through to their Local Government committee.

Every Penny Counts

We all know that every penny counts. Lawmakers are faced with the pressure of passing initiatives that will support vital emergency services while at the same time balancing a tight revenue stream that does not inordinately raise taxes for their constituents.

We will continue to follow these important pieces of legislation as they advance in these States. Certainly, there will potentially be other State lawmakers across the nation who will look to their counterparts for the overall outcome.

*The article, ”Bill would allow fire departments to recover costs of EMS services” published by The Legislative Gazette on 5/22/2018 is the source for New York State ambulance service statistics reported above.

Ordinary People Doing Extraordinary Things

2018-05-25T10:13:00.000-04:00

Amazing!

You are amazing!

You- yes, you…Mr, Ms, Mrs…paramedic, EMT, nurse, doctor….ground-, air-based…you are amazing!

In case no one told you that in the last week as we celebrate EMS, please allow all of us here at Quick Med Claims to pat you on the back and call you out for the hero that you are.

It Doesn’t Matter…

It really doesn’t matter what role you play nor how long you’ve been involved in EMS. You matter! You are a big deal!

From the folks in the air, on the street to those in the office and especially those of you who volunteer by giving your time, knowledge and expertise in whatever role you play; just know that while you may not hear this every day from those you serve- they definitely appreciate you.

We appreciate you!

Look How Far…

Look how far EMS has come.

As first responders to all things medical transportation-ish we have made enormous strides. Everyday lives are saved because those who came before us were willing to think outside of the box and come up with new ways and new equipment, and might we say new money, to develop a constantly evolving and every-changing new system to make this all happen.

Our list of incredible “toys” has grown, but more importantly you all have grown. The skill and education that today’s EMS requires is mind-boggling. It takes you to make that cardiac monitor transmit a digital image to the ER doctor. It takes you to properly apply the Lucas Tool to deliver flawless and consistent chest compressions. It takes you to get the IV started in a moving vehicle with potholes and bumps and turns and twists, administer the correct medication in just the right dosage that saves the life and preserves a family yet another day.

Maybe you’re the new Community Paramedicine paramedic. Your visit to Mrs. Jones’ house to look in on her may just be the only visit she receives today. You leave with the satisfaction that this widow can rest knowing she has achieved her health goals for the day plus she’s a bit less lonely for your having stopped by. Mobile Integrated Healthcare at its finest and you’re the pioneer on the forefront.

We can go on and on…you know who you are.

The Nasties!

On TV, the Station 19 crew always has the “big one” and it always works out in the end.

Fast-forward…real world…not so much.

For every “big one” there are ten “not-so-big-ones”…like the trip from the ER discharging to the SNF. Or there’s the guy who had a few too many tall ones that pukes on your nicely mopped ambulance floor which now you’ll mop and disinfect again.

There’s the brand new uniform pants that now has blood on them and it won’t come out.

There’s the overdose victim that lives for another day because of that vial (or two) of narcan the wonder drug that you just administered and while you feel relieved that he lives, somehow you know that you’ll be back again tomorrow at the same location for the same patient. So…you provide a bit of fatherly/motherly advice; “Get help!”…and yet help evades these people over and over.

But you keep going. Though the nasties, through the routines and the not-so-routines.

You keep going on and on missing lunch, stretching those bathroom breaks to the point of explosion and you do it on two hours sleep here and there. Along the way, you struggle to take care of yourself- try to eat right, try to forget, try to cope and yet you still feel the rush when you know that you completely stood up to death and you won!

Unless you do it…

From the billing office window, we are in awe of you. We see first-hand what you do and are continually amazed at your accomplishments. You are a true superhero in every sense of the word.

Unless you do this thing that we all do, be it in the office or in the field; few people outside of the first-responder world will ever really “get” why and how you do it. To them you may just be an “ambulance driver” but to us you truly walk on water.

But, what really amazes us is the fact that you take it all in stride. It’s another “day at the office” and yet countless people enjoy another day of life because of YOU! That’s a big deal!

THANK YOU! As we close out this EMS week, we truly say THANK YOU!

You rise with humanity to permanently impact the lives of everyone you touch. The debt of gratitude that society owes you is immeasurable.

Be safe! Happy EMS Week!!

The Moms of EMS- A Tribute

2018-05-11T10:46:00.000-04:00

Sunday

Sunday’s a big day!

It’s Mother’s Day. It’s a day that we celebrate the one person we literally cannot do without simply because…well…we physically wouldn’t be here without our moms.

And…that got us thinking about the Mom’s that make up EMS. What will their Sunday look like?

ALERT!

It’s all about the alert!

You know, the dispatch. Whether it be a Minitor chirping, an alpha-numeric pager tripping or the Active 911 blast across the cell phone screen, it’s bound to interrupt mom’s day.

Many of our EMS moms are volunteers. The person with an emergency will pay little mind to the fact that Sunday, Mother’s Day, is set aside to honor those EMS moms. The heart attack, stroke, motor vehicle crash…unfortunately, does not know that this day is meant for rest, relaxation and pampering.

It happens and almost always just when we all sit down for a nice meal or meaningful conversation with that mom. Maybe it’s the daughter who just sat down to tell mom how important she is and off trips the pager. Maybe it’s the mom who just welcomed her son for a Mother’s Day visit but Mrs. Smith down the street fell and needs EMS.

Off runs mom to answer the alert and everyone at home is just going to need to sit tight and wait for mom to return to celebrate Mother’s Day.

Career Shift

An EMS mom can be a career staffer at your community ambulance service. Sunday is her day to work regardless of whether or not the calendar says it’s Mother’s Day.

Hallmark card aside, today is a work day. There are lives to save and people to move.

So, off to work mom goes. Maybe her Mother’s Day was the day before or maybe it will be Monday, the day after. But, duty calls and since EMS never takes a day off “the show must go on.”

Supporting Cast

EMS moms aren’t just limited to the providers. Think about all of the moms of EMS that work in the office.

Near and dear to our heart, here in the billing office, are all of the moms that fill our incredible billing chairs. These ladies (and men- but today we celebrate the moms) work diligently to support the field operations. Without their tireless work there would be little to no financial resources to support those vital field ops. Take these ladies out of the equation and the EMS machine would grind to a screeching halt because there would be no financial fuel to keep things humming.

On top of the billers, there are those moms that sit on boards of directors, take care of human resources, pay the bills, order the supplies and…on and on and on.

The Multitaskers

In this tribute to our EMS moms, we recognize the moms who are the multitaskers.

In our opinion, EMS moms- more than most- bring multitasking to a whole new level. Before and after moving patients, they move a lot of people and “stuff.”

The EMS mom moves her family on the heels of moving her patients. There are little people to move to soccer practice, dance recitals or music lessons. The groceries must be purchased, loaded, unloaded and the food must be prepared (or McDonalds must be retrieved for those pressed for time.)

The bills at home must be paid, clothes washed, sleepy people to be roused and then there’s (maybe) time to fall into bed and do it all over again- that is unless mom’s shift at the ambulance station is third shift.

EMS thrives on many tasks, constant activity and little sleep. We’re of the opinion that the EMS mom is THE BEST at this over any mom created. God gave special super-human skill and ability to the EMS mom…and it shows.

Take a Bow!

In closing, will the EMS mom reading this post please…TAKE A BOW!

You’ve earned our highest respect and admiration. You are the embodiment of the Super Mom!

Thank you to those of you who make the time to be awesome in the role you play to protect the life and health as part of the EMS system.

Sunday’s YOUR day.

Happy Mother’s Day!

Emergency! – Digging Deeper to Define

2018-05-04T09:43:00.000-04:00

Bloggers Note- this week our billing office had a discussion with a client to help provide direction on the question of what constitutes an emergency and the documenting of the use of “lights and sirens”. The discussion is common. Just about two years ago, we added a blog post that addressed this very subject, so we thought it would be a good idea to resurrect that post and remind everyone of the rules. We hope you enjoy the content.

Lights and Sirens Myth

This billing office is often questioned about what constitutes an emergency for the purposes of billing and collecting payment.

There’s a myth in EMS that any ambulance incident that necessitates the use of “lights and sirens” is an emergency. It’s not the case.

We look to Chapter 10 of the Medicare Benefit Policy Manual as published by the Center for Medicare and Medicaid Services (CMS) for the definition most widely used. Surprise! There isn’t a mention of lights and sirens anywhere in the definition.

We need to know…

Whether you’re an EMS field provider, an EMS administrator or both it is important that you know and understand the definition of what constitutes an emergency in the ambulance billing world. We argue that many of our street-level providers are never adequately schooled on the rules, yet we expect them to provide pinpoint documentation regarding their emergency scenario when they have no clue on how to tell the billing office what it is they need to tell us in order to define the scenario as emergency or non-emergency.

In the world of the street provider, you turn on the light, hit the siren and get a move on- that’s an emergency.

Not so for billing later.

The Definition

CMS defines an ambulance “emergency” as…

An emergency response is one that, at the time the ambulance provider or supplier is called, it responds immediately. An immediate response is one in which the ambulance provider/supplier begins as quickly as possible to take the steps necessary to respond to the call.

In explaining the application of the definition, CMS further elaborates…

The determination to respond emergently with a BLS or ALS ambulance must be in accord with the local 911 or equivalent service dispatch protocol. If the call came in directly to the ambulance provider/supplier, then the provider’s/supplier’s dispatch protocol must meet, at a minimum, the standards of the dispatch protocol of the local 911 or equivalent service.

Again...specifically noting for emphasis…not a single mention of lights and sirens.

Let’s pick it apart…

Looking at the definitions and application instructions above, what is it that is required to be in the Patient Care Report documentation in order to affirm to the payer that the trip can be billed as an emergency?

First, make sure that everyone is documenting how the dispatch was received. Most likely it has been received via the 9-1-1 public service access point (PSAP). You’ll find above that the rules do allow for what we all refer to as a “direct call” when the office phone rings at the station as opposed to a 911 center but it should be stated in the PCR that the call was emergent or life threatening in nature. For the regular phone to ring with an emergency requires that the ambulance office where the phone is answered follows the same protocols as the nearest 911 center which necessitates some set-up behind the scenes (another blog, another time).

Second, we must be sure to educate the provider staff about documenting the response. Notice the rule spells out that the ambulance crew “…must begin as quickly as possible to take the steps necessary to respond to the call.” A standard alert-to-response time frame, such as in a volunteer-staffed ambulance scenario or where there are complicating factors such as inclement weather, etc., simply needs to be explained in the written narrative.

Documenting the means of dispatch (911 or equivalent) and documenting the “immediate” response are the two big ticket items that must be clearly spelled out in the Patient Care Report to enable your billing office to properly bill the EMS scenario out as an ALS or BLS emergency.

Suggestion

Finally, if possible it never hurts to include documented verification from the 911 center. Many systems are now providing Computer Aided Dispatch (CAD) recaps which can either be electronically scanned and attached into an ePCR system or appended to the written documentation to be passed-on to the billing office. Having this information available is proof-positive of the nature of dispatch and even backs-up the response times of the scenario.

Balance Billing and Air Medical Transport

2018-04-27T09:34:00.001-04:00

Part Two

Welcome to Part Two of our blog series Balance Billing and Air Medical Transport. Last week, we looked at the historical aspect and defined the issue at hand. This week, we peer into the public perception, regulatory consequences, and make some suggestions on how to navigate the changing Balance Billing landscape.

Public Perception And Consequences

Because the financial implications of balance billing for air medical and other pre- and inter-hospital transports can be so significant, the concept of Balance Billing has come under a great deal of scrutiny in recent years. While our concern here is the medical transport industry, emergency departments, emergency physicians and other high-profile providers/suppliers are also under a great deal of scrutiny. Several national health care organizations, including one that provides emergency physicians services, have come under great pressure to end the practice. United Healthcare actually has a web page dedicated to educating consumers about the implications of balance billing performed by a specific organization. In certain circumstances, a single” high profile” case can bring tremendous outside pressure on Balance Billing practices.

More than 550,000 Patients in the U.S. use air ambulance services every year. The number of dedicated air ambulances in the U.S. has more than doubled in recent decades. Factors contributing to this growth include a decline in the availability of emergency services, changes in the delivery of health care in rural settings and the growing age of the population. There are also concerns that this proliferation has resulted in medically unnecessary use. In addition, the philosophy of many providers/suppliers has been to offer services as an “out of network” or “non-participating” entity. This means that the entity is not obligated to accept insurance payments as payment in full. One could argue that third party payments such as those offered by Medicare, Medicaid and many commercial insurance companies are not adequate to cover the cost of providing the services. The result is that many individuals find themselves with increasingly substantial financial responsibility after receiving these lifesaving services.

Legislative Action

There are a number of legislative authorities and regulatory agencies that are keenly aware of the impact of Balance Billing. A law was passed in North Dakota several years ago that requires 911 operators to contact “in-network” air medical providers first. The legislature in Montana has taken up the matter and is currently considering legislation that would place limits on billing practices for air medical transport. The unique application of the Airline Deregulation Act (ADA) in the air medical transport industry is a barrier to state efforts to regulate the industry and protect Patients. The ADA restricts the ability of states to regulate “rates, routes and structures” as it relates to using aircraft to provide services. What remains is an environment where providers/suppliers continue to offer these services and Patients may end up with responsibility for tremendous financial responsibility afterward. This impasse has brought great outside scrutiny to an industry that is already highly regulated and, in many cases, has put providers/suppliers in direct conflict with the Patients they serve.

Solutions And Strategies

In order to overcome the challenges faced by the medical transport industry, it is essential to have an organized approach to the Balanced Billing challenge. Providers/suppliers should be thoughtful and consistent in their approach. The following are strategies that Quick Med Claims suggests to our Clients:

Follow Applicable Laws & Regulations You must always be aware of applicable laws and regulations that apply. This has become more challenging as more rules and regulations are promulgated in response to the public perception. Your organization should always adhere to applicable laws and regulations.
Set Charges at a Reasonable Level In order to avoid scrutiny and negative perceptions on the part of key stakeholders, the provider/supplier should seek to set the charges for services at a reasonable level. One school of thought is to set charges in a fixed relationship to the cost of providing the services. In other words, it is advisable to understand the cost of providing the service and set the charges at that figure PLUS a reasonable mark up.
Be Proactive in Educating the Stakeholders It is advisable to educate the key stakeholders about the cost of providing the services, the methodology used to derive the charge structure and the policies that apply with respect to charity care. In addition to the Patients that are served, stakeholders include insurance companies, the government, employers and the communities served.
Have Written Charity Care Guidelines and Follow Them It is imperative that every provider/supplier have a well-considered, written charity care policy that defines very specific criteria for how self pay balances are resolved. The policy should be followed consistently over time to avoid risk.
Provide Fair and Reasonable Payment Options Each provider/supplier should have a specific approach to offering reasonable payment terms for Patients. As the Patient responsibility portion of air medical claims continue to grow, it will be important for the provider/supplier to offer fair and reasonable options for payment.

Wrapping Up

It is often difficult to find a balance between providing these important and valuable services to the communities we serve and maintaining our financial viability as a medical transport organization. The cost of providing the services continues to rise and the financial burden for our Patients continues to rise. Be proactive in your approach to Balance Billing and resolving financial responsibility for the services that you provide.

Balance Billing and Air Medical Transport

2018-04-20T10:15:00.000-04:00

Bloggers note- Welcome to Week One of a Two-Part blog series focusing on Balance Billing and Air Medical Transport. This week we’ll look at the issue at hand complete with a brief history lesson on how we arrived at today and where things stand currently with regard to the practice. Next week, we’ll look at the public perception of the balance billing practice and even make some suggestions on how to navigate the changing balance billing climate. While this series focuses heavily on Air Medical Transport, there are definite takeaways for the ground ambulance sector, as well.

Billing Patients

Healthcare providers and suppliers have a long history of billing Patients for services. This process occurs in several different circumstances. It can be appropriate when the Patient does not have insurance coverage for the services that have been provided. It can be appropriate when the Patient has not yet met the deductible for their insurance coverage in a given period. It can be appropriate when the insurance coverage requires the Patient to be responsible for a predefined co-pay amount for the services provided. It may also be appropriate when the insurance company has paid an amount less than the provider/supplier’s CHARGES for the services provided. In the latter circumstance, the term of art for this process is called “balance billing.”

Balance Billing Defined

Healthcare providers are one of the few professional groups that have little to no control over their compensation. Unlike accountants, lawyers, consultants and other professional groups, healthcare providers/suppliers are frequently asked to accept compensation for services that has no relation to their actual charge for the services. In many cases, this determination is not made until AFTER the services have been rendered. It is quite common for the payors who are responsible for paying for services rendered to apply seemingly arbitrary standards to derive an amount they believe is appropriate payment for the services. This amount may be call an “allowable,” “usual and customary charges” or some other derivation; however, the outcome is the same… providers/suppliers are left with a shortfall between their charges and the amount they receive from the payor for the services provided. Try that with your local plumber, your estate attorney or your accountant at tax time. I suspect the relationship will not be a longstanding one. Unfortunately, medical transport providers/suppliers are accustomed to operating with this burden.

When the provider/supplier is not obligated to accept the lower payment as payment in full, by regulation, contractual agreement or some other compelling circumstance, the entity may bill the Patient. The act of attempting to collect the difference between the CHARGES for the services rendered and the amount paid by the insurance company is called “Balance Billing”.

The Challenge of Balance Billing

This practice of Balance Billing in medical transport is often viewed in a different manner than our relationships with other professionals as noted above. This difference may result from several aspects of our situation. It is often difficult for us to provide a firm estimate of the charges in advance of the services being rendered. Whether it is because the situation requiring care is unfolding in an emergency circumstance and/or because the needs of the Patient are evolving as the care is provided, providing an estimate of the charges may not be practical. In addition, the financial responsibility for the services rendered are often detrimental to the Patient in economic terms. While Balance Billing for ground medical transport services may not be as onerous an economic burden, the order of magnitude for air medical transport is such that this financial responsibility is often much more catastrophic. Likewise, the perception of the value of the services provided can be very different than the charges for the service.

For example, a quick review of air ambulance providers using this billing office finds the average Rotor Wing base rate charge to be in excess of $17,000, yielding an average charge per transport in above $25,000. Many large Rotor Wing providers are generating an average charge per transport of twice that much. The trend has included double digit increases in charges year over year. Not that it is easy to put a value on lifesaving services and care, but the reality is that many stakeholders have no concept of the COST of providing the services.

Medicare Prior Authorization- Part II- Impact!

2018-04-13T09:16:00.000-04:00

Welcome!

Thanks for stopping by for Part II of our blog recap of the findings from the recently published interim evaluation report on Medicare Prior Authorization.

Last week, we capsulized the findings as published by government contractor Mathematica Policy Research. This week, we will briefly take a look at the impact, now and for the future.

How’d we get here?

When Dutch Physician Willem Kolff created the “artificial kidney” dialyzer in 1943, he could have never foreseen the massive impact on the lives of patients around the globe. Even despite Nazi occupation of his homeland, Kolff pushed his invention forward after helplessly watching one of his patients suffer an agonizing death due to advance kidney failure.

Fast forward 19 years later to 1962 when University of Washington medical professor Dr. Belding Scribner found a way to bring dialysis treatments to the masses by developing the first-ever outpatient procedure.

Once this process was refined and the benefits to End Stage Renal Disease patients was proven, outpatient dialysis centers mushroomed from the hospital setting to locations dotted across the map over the next few decades.

With the growth of treatment possibilities, came the need for transport of patients to and from such treatments.

Big Bucks!

It didn’t take long for ambulance providers and suppliers to figure out that 6 transports per week per patient could compute to a nice predictable and steady cash flow.

That’s where the problem started.

To provide some context, we once had a for-profit ambulance proprietor tell us that it was a “no-brainer” for him to find as many dialysis patients that he could convince to use his service for transport because just 3 or 4 patients meant a revenue stream of six figures per year with relatively minimal effort and costs expended on his part to provide the service. And…the bulk of his revenue came from “guaranteed” (his words) government entitlement programs (ie. Medicare.)

And…he was right- at the time.

Then the ball dropped…

However, many of the RSNAT dialysis-trip ambulance providers were not the norm for the EMS industry. The ambulance operators were hastily organized, often did not follow medical necessity guidelines and in some cases fraudulently completed false documentation in order to justify payment from Medicare for these trips. These unscrupulous operators were “stealing from the government” to the tune of many millions of dollars and something had to be done.

The Medicare Prior Authorization program was designed as a way to combat this fraud and abuse of the system. In Year 1 of the Prior Authorization demonstration project, the Mathematica report showed a drop in RSNAT Medicare ambulance utilization by 65.78%, most of which represented transport of ESRD patients to and from dialysis.

When expenditures dropped for RSNAT per beneficiary by a whopping $432, a 90 percent decrease, so did the number of ambulance providers in the model States. In fact, average quarterly expenditures on all Medicare ambulance services per beneficiary with ESRD declined by $523 which in all translated to an approximate Medicare savings to the tune of $171 million.

The decline in the number of EMS agencies per 100,000, according to Mathematica, checked in at 38 per 100,000 Medicare beneficiaries down from 46 per 100,000 in 2012. In Year 2 of the project the drop dipped to 30 per 100,000 nationwide with the model states falling to 25 EMS agencies per 100,000.

The tension arising from the findings of the study, does make note that there was a spillover negative effect on legitimate ambulance providers and suppliers who were transporting truly medically-necessary patients to and from treatments. Additionally, the report noted a spike in the use of emergency ambulance services soon after program inception and while hard to extrapolate, there did seem to be a direct correlation between fewer transport options for patients who then extended their dialysis cycle to the point that their condition worsened and became emergent or they simply dialed 9-1-1 to request transport because they could find no other viable option once the smaller, dialysis-centric EMS agencies folded from the cash flow drain.

The decrease in the number of EMS agencies was even further magnified in Pennsylvania and New Jersey where, coupled with prior authorization; a moratorium on the credentialing of newly established non-emergency transport providers was put in place by CMS for the geographical area comprising the greater Philadelphia metropolitan area.

Change and Dialogue

This first report now begins a dialogue between the ambulance industry and Congress by way of CMS. A legislative roadblock has now been overcome allowing CMS to extend the program to the entire United States.

It will be interesting to see if that takes place in the days ahead.

Additionally, we now fully know that there was an over-utilization of services with some ambulance operators that were not totally playing by the rules. Using this report and further analysis, we all can come to a consensus on how to best legally use Medicare dollars wisely while still providing services to those patients who truly require RSNAT transportation.

Stay tuned!

Medicare Prior Authorization- Results 3 Years Later

2018-04-06T12:40:00.000-04:00

History

In December 2014, the Centers for Medicare and Medicaid Services (CMS) implemented a Medicare Prior Authorization program on a three-year trial for RSNAT- repetitive, Scheduled, non-emergency ambulance transports. The program targeted three States that statistically showed a sharp increase in these types of transports at an alarming rate when compared with other states (ambulance usage approximately 50 percent higher.) The States included New Jersey, Pennsylvania and South Carolina.

CLICK HERE TO VIEW THE REPORT

Later in January 2016, Phase II of the trial driven by the Medicare Access and CHIP Reauthorization Act of 2015 (MACRA) expanded the RSNAT prior authorization model to six additional states. Phase II states included Delaware, the District of Columbia, Maryland, North Carolina, Virginia and West Virginia.

As required under the program, CMS engaged Mathematica Policy Research, a nonpartisan think tank, to conduct a five-year evaluation to study the impact of the prior authorization model. Mathematica used guiding research questions across five “domain” areas- Cost Savings, Quality and Access, Program Operations, Suppliers and Providers and Improper Payment Rates. The report also capsulizes the implications of the findings and highlights the major lessons learned from the project.

Interestingly, but not surprising, the report wound up focusing heavily on End Stage Renal Disease (ESRD) patients who accounted for more than 75% of the repetitive transports reviewed. The transports of ESRD patients has long been the focus for CMS which has continually been questioning the medical necessity and reasonableness in justifying payments for those patient transports. The Feds even moved to combat the growth in ESRD slicing payments for those transports below the normal Medicare National Ambulance Fee Schedule allowances, twice, with the most recent cuts coming just this year.

The research project ended one month ago when Mathematica released its report titled First Interim Evaluation Reports of the Medicare Prior Authorization Model for Repetitive Scheduled Non-Emergent Ambulance Transport (RSNAT). The extensive report amasses just shy of 100 pages of findings and data to support those findings.

Cost Savings

Mathematica reports that the prior authorization program reduced Medicare payments for RSNAT service expenditures for ESRD beneficiaries by $171 million across the nine participating states. That is a decrease of at least 80 percent in service utilization and costs in those model states for ESRD beneficiaries.

The report cites that stakeholders in the program perceive that the prior authorization model is achieving success in addressing the fraud and abuse connected with these types of transports. The results appear to be significant enough that we can only deduce that the program will soon be expanded to include the entire United States, although no concrete plans have yet been announced for implementation. The reason for this delay was for the review of the impact report. Now that this report has been released, it would seem logical that CMS will recommend to Congress that the program be expanded to save resources and protect against improper payments.

Quality and Access

The report cites “little or no” impact on quality and/or adverse outcomes for ESRD beneficiaries backed up by studies of emergency department visit reviews, emergency ambulance utilization reviews as well as an analysis of unplanned inpatient admissions and even death. However, Mathematica’s research did find that there was a 15 percent spike in emergency dialysis use, suggesting a delay in ESRD treatment minus a transportation option for some of these patients.

Mathematica did find that there were some beneficiaries who qualify as medically necessary patients who experienced delays and/or missed treatments because of the time required for the ambulance to receive the prior authorization from the Medicare Administrative Contractors (MACs). Additionally, non-medically-necessary patients had trouble finding a transportation option to and from dialysis treatments because of the overall affect the program had on ambulance agencies in the nine program states.

Program Operations

It’s not a shock that the MACs reported successful implementation of the program overall. Why wouldn’t they say that? They are protecting their own skin in the game here (this blogger’s opinion, of course.)

Phase I or what the report calls “Year 1” states had a more difficult roll-out than “Year 2” affected MACs as the first phase MACs were creating a new program from scratch which is a logical explanation.

Suppliers and Providers

Big effect here!

The report documents a 15 percent decrease in the number of ambulance suppliers per 100,000 beneficiaries in the model states following the Prior Authorization Model implementation. It was noted that the suppliers that left the program were generally smaller companies that relied heavily on RSNAT transports for the bulk of their Medicare and overall operating revenue.

There were complaints recorded by stakeholders, most notably physicians, who claimed they received little or no advance notice or educational material regarding the prior authorization program implementation. These stakeholders indicated that the medical necessity determinations used to issue or deny the prior authorization were too strict and the medical necessity guidelines were not clear to the stakeholders, again primarily physicians, prior to the beginning of the trial program.

It appears that CMS and the MACs must still improve on their educational initiatives at all levels, not just for the ambulance industry participants.

Improper Payments Rates

Mathematica noted “data challenges” that made it difficult to properly assess whether the Prior Authorization model had an impact on improper payments. In fact, rates of improperly paid claims for all Medicare ambulance services actually increased during the analysis period.

However, it was noted that upon program model implementation the MACs issued denials more aggressively noting increased vigilance on the part of the MACs given their recognition of the program rollout.

Coming Next Week…

We’ll look at the report’s conclusions and possible implications next week in this space. We hope you’ll check back in again!

Other Methods of Transportation are Contraindicated

2018-03-23T10:33:00.000-04:00

Medical Necessity Defined

We talk a lot about Medical Necessity in the ambulance billing office. Medical necessity and Reasonableness are key in determining whether or not an insurance payer is obligated to pay for ambulance transport, especially for Medicare and Medicaid patients.

Title XVIII of the Social Security Act defines the very Medicare ambulance benefit as “ambulance service where the use of other methods of transportation is contraindicated by the individual’s condition…”

The Social Security Act spells out that the deciding factor in allowing payment for all ambulance claims submitted for payment. Documentation explaining the ambulance transport must be clear making a case that the patient could not have been safely transported from origin to destination by any other means of transportation without jeopardizing the patient’s health.

Internal Guidance

Internal guidance released by the Centers for Medicare and Medicaid Services (CMS to the Medicare Administrative Contractors (MACs) provides guidance directing when to deny payment on ambulance claims.

CMS stresses that each individual’s medical condition must be explained using words that describe the patient’s “clinical medical necessity” leaving no doubt that the patient was unable to use another mode of transportation other than an ambulance.

CMS instructs, “It is important to understand that this clinical medical necessity aspect is a component of the definition of the benefit…”

A Benefit, Not a Right

Many of us in the ambulance industry look at Medicare, Medicaid and even Commercial Insurance coverage as somehow being our “right” to be paid just because we turned a wheel.

If we had a dollar for every time we have heard…

“If the patient calls 9-1-1, we must respond and we pretty much have to transport so we should be paid!”

Or, in the case of a non-emergency/routine transport…

“If the doctor believes that the patient needs to go by ambulance then who is Medicare to say that they shouldn’t pay? The doctor knows best. They call. We transport. They should pay!”

Unlike the basic rights and liberties that we enjoy as Americans, we hate to burst your bubble but universal coverage for ambulance transports is NOT a right. Insurance coverage is a benefit. But it is a benefit contingent on the patient’s meeting the stated criteria and that criteria boils down to one basic concept for most payers.

Transportation of the patient by any
other means is contraindicated!!!

Often Misunderstood

The concept of Medical Necessity is often very much misunderstood by the ambulance provider community. As providers, all of us are birthed in our careers by the notion that when the pager activates we have a duty to respond.

Likewise, we somehow extend that duty into the notion that the insurance payer (Medicare, Medicaid, Commercial…) must always pay.

Not so!

The phrase Medical Necessity is a two part concept that must be understood as…

Clinical- did the patient medically require an ambulance such that transport by ambulance was the only way to safely move the patient to a destination for the diagnosis or treatment of illness or injury or to improve the functioning of a body member?
Statutory- has the transport met the payment criteria outlined in the insurance payer’s rules defining the benefit?

There are no givens!

There are no givens in the ambulance billing industry. We must prove each claim using clear clinical documentation recorded by the patient care provider supporting the fact that the patient would have been endangered and literally had no other means of being transported from Point A to Point B safely except in an ambulance.

It’s the provider’s burden to explain in the Patient Care Report (PCR) that some form of diagnosis or treatment of an illness or injury to improve our patient’s qualify of life was performed during the ambulance transport in order for the payer to make payment for the transport.

In the end, ultimate medical necessity proof resides in the PCR which explains in detail the overall condition of the patient necessitating the level of service and care provided during the transport.

Understanding Ground Ambulance Charges-Part III

2018-03-16T10:57:00.000-04:00

Ambulance Billing is Different

Ambulance billing is different.

Really medical billing as a whole is different than any other type of billing or business practice, but ambulance differs at yet another level than even other medical billing disciplines.

In any other business line, one makes a product or delivers a service. The business then charges a price per unit that reflects the costs of producing that product and factors in a margin to not just cover the cost of the product or service, but also hopefully makes the business a profit.

Not so for the medical world.

Widgets

In the medical world, while a procedure or service including an ambulance transport is priced by the service provider or supplier, there is not a guaranteed direct tie to the amount of reimbursement that is received in many cases.

Pricing in any other business line reasonably reflects the expected amount to be collected upon delivery or the sale of the product. In other words, if I am the manufacturer of widgets I determined that I make a widget that costs 50 cents per widget. I decide to price your widgets to sell at $1.50 per widget.

Happily, I make 100 widgets and sell all 100 widgets at full price.

I’ve spent $50.00 to manufacture the widgets and sell them for a total of $150.00 realizing a profit of $100.00. I’ve now covered my costs and have a tidy little profit left over after paying for my costs.

Introducing the Contractual Allowance

In the medical world, pricing is determined based on cost as well. However the direct reimbursement tie-in to the “sale” and delivery of the service or procedure is not quite as clear as with the widget manufacturer.

The medical provider or supplier may arrive at a price but never see the full collection of that pricing.

Let’s say that the hospital decides that a surgical procedure will cost $5,000 to deliver when all is said and done. So, they price out that procedure at $7,500 intending to realize a $2,500 reimbursement to re-invest in technology or operating overhead.

However, the patient is a Medicare beneficiary and Medicare’s fee schedule allowance for that procedure has been set by the Federal Government at $6,000. Medicare pays the hospital and the surgeon the $6,000 allowance and decides that the patient has a co-pay of just $200.

When the patient pays his $200 co-pay the remainder of the $7,500 charge must be dropped and cannot be collected. The hospital corporation and the surgeon forgoes $1,300 less than their full pricing on the procedure.

This is referred to in medical billing as a “Contractual Allowance.”

The Contractual Allowance is the difference between the Gross Charge and the amount realized from the billing process that cannot either by law or by contractual agreement with the payer be collected on the bill either from the insurer or the patient.

Ambulance Application

The same applies for ambulance but with a fairly significant difference.

The ambulance cannot always know the reimbursement level up-front, nor can it choose to deliver or not deliver the service based on that potential reimbursement.

For example, My Town Ambulance Service has determined that it costs $450 to place an ambulance on the street each time the alert tones sound for an emergency.

Let’s say that the patient is a Medicaid beneficiary and lives in Pennsylvania. The Commonwealth has determined that Medicaid pays a whopping $200 when billed for an Advanced Life Support transport (plus mileage at $2.00 per mile when the transport exceeds 20 loaded miles- but we’ll assume for our explanation that the transport does not exceed 20 miles.)

So, My Town Ambulance has just spent $450 to complete the transport and yet will be was reimbursed just $200, now realizing a loss of $250 even though Medicaid paid the bill submitted by My Town in full. The Contractual Allowance is that $250 and cannot be collected from any source.

No Payer Source

Finally, the ambulance service may apply a Gross Charge and Mileage Charge to a particular incident, yet learn that the patient has no insurance coverage and lacks the means to pay.

Now we move from a Contractual Allowance to a potential Write-Off or more aggressive collection activity season. In any event, money was spent maintaining a “readiness to respond” and yet may not be able to collect enough dollars to just break even with the costs to provide the service to the public they serve.

Understanding Ground Ambulance Charges- Part II

2018-03-09T11:53:00.000-05:00

Last week…

Welcome back to Part II of our series “Understanding Ground Ambulance Charges!

Last week we covered the basics. We defined the term charges and what it means and how it applies to the ground ambulance billing world. This week we focus on how charges are determined and by whom.

Strike the Myth

Because our role in this billing office is one of an outsourcing nature, we are often asked if we – the billing contractor – can simply set gross charges for our clients.

The answer is no. We cannot.

While we understand that our clients, especially our volunteer-based clients, see this as a value-added service provided by “the experts” in the business, there are just certain risks involved that prohibit us from making those determinations.

Each EMS agency is a separate entity. The ambulance providers and suppliers that we serve all operate in varied markets. The costs to provide the service differ. Local demographics differ.

In some States there are limits, one or two States, actually determine the charges an EMS agency can use when billing by setting those rates in a tariff system which must be approved at the State government level monitored by a regulatory agency. Even some localities have prohibitions that are set by municipal and county laws dictating what an EMS agency can or cannot charge.

So we’ll use this space to strike the myth that it’s the ambulance billing company’s responsibility to set gross charges for their client accounts.

Comparisons

What a billing office like ours can do is provide data to assist clients in making decisions about what to charge.

You can use comparison reviews based on what others are charging in the industry to help you make decisions using information regarding what other EMS agencies are doing (without divulging the individual agency identities, of course.) Reviews are useful when you can compare other agency charges by geographical region, size and scope of practice as those charges reflect the inherent costs other agencies like your’s is incurring as reflected in those fee schedules.

Our clients find it helpful to have this data at their fingertips.

Charges Reflect Cost

Of course, with reason, the charges you use typically will reflect the cost to do business.

When considering the Gross Charge fee schedule you will employ, consider using charges that reflect a fair approximation of the cost to provide the services you offer to your community when providing EMS services.

If your service is a non-profit or a municipal service, it’s likely you may need to explain the rationale for what you charge to the public. If your EMS agency is a for-profit, you’ll certainly be considering the competitive nature of how your agency’s charges stack-up against your nearest competitor while still insuring that you are not“deep discounting” your charges and thereby creating a compliance issue for your agency.

There reasonably should be some logical explainable reason(s) for determining your fee schedule. We know that our clients tell us they take into consideration the ethical considerations by being as fair as possible with the community they serve while still insuring an adequate cash flow to insure the sustainability of the service over the long haul.

A healthy bottom line equals a health EMS system.

Who Chooses and When?

Ultimately, then, who makes the final decision on what Gross Charges are put in play?

That depends.

Each EMS agency follows their leadership and decision-making process. We find that Boards of Directors, administrative leadership, elected officials…a varied number of decision-makers make the final decisions about the Gross Charges used in their fee schedules.

Whatever the case may be, it is a good idea for your EMS agency to periodically review charges to insure that you are keeping up with the changes in the costs to provide the service and what the overall market is dictating as a whole.

Your EMS agency’s Gross Charge fee schedule drives revenue which funnels reimbursement dollars to you so you can operate in your EMS system. Failing to stay on top of this important factor, will stagnate your EMS billing program and potentially hamper your ability to drive adequate funding back to your agency.

Understanding Ground Ambulance Charges

2018-03-02T09:21:00.002-05:00

Often Questioned

Here at the billing office, we are often questioned about the gross charge fee schedule used by our clients when billing. This is a line item list of charges that are included on the bill and combine to create a total dollar amount bill for the services offered by your EMS agency.

We’ll use this blog space for a few weeks to review what the charges do and look at topics such as who sets the charges and how are they determined, how do they play a role in your billing picture and ultimately how do they determine the overall success of your department’s ambulance billing program.

3 Charge Types

There are basically three types of charges and they are Base Rates, Mileage and the all famous “Other” category.

Let’s make an attempt to describe each type.

Base Rates

For ground ambulance billing, a Base Rate typically depicts the level of service provided along with the priority. So an EMS agency, depending on the services they provide as licensed or permitted by either the State(s) and/or local municipality(ies) they serve, will most likely include these basic Base Rates as part of their gross charge fee schedule.

ALS and/or BLS Emergency (Level I)
ALS and/or BLS Non-Emergency (Level I)
ALS 2
Specialty Care Transport (SCT)

Of course, if your EMS agency provides other transportation options then you may also include Base Rate charges for stretcher van, invalid coach, wheelchair van and then there may be variations on the theme such as separate bariatric charges, event-related charges, payer specific charges, lift assist, treatment/no transport and so forth.

The charge is applied based on the level of service called for and/or provided which is supported by the field provider’s documentation. A specific level of service code called a HCPCS or Healthcare Common Procedure Coding System code is applied in the billing office and computed out onto the bill submitted for reimbursement. The base rate charge is calculated using the number of individual usage units utilized in the ambulance scenario (typically 1 unit or 1 transport trip leg per incident.)

Mileage

Mileage charges are set to typically depict the amount of what we call “loaded miles” which is the sum of the distance traveled when the patient is in the ambulance for transport. Mileage charges are set at a per mile rate and then multiplied by the number of miles traveled while transporting the patient.

Several years ago when the Centers for Medicare and Medicaid Services (CMS) mandated mileage to be billed to Medicare to the nearest tenth of a mile, it was necessitated that our charges be set to multiply when billing Medicare and those payers who followed suit and adopted a tenths of miles payment system, mileage calculation for billing was adjusted to account for the tenth factor.

Ground ambulance field providers are expected to record the odometer reading at the beginning of the transport or at the pick-up/origin location. Then upon arrival at the destination location where the patient has been delivered, the odometer reading value from the ambulance vehicle is once again recorded. The mileage amount billed is determined by the amount of miles traveled between the two points.

Again, when billing, a HCPCS code representing mileage billed is applied to the bill that is generated to the payer source. The per mile charge chosen by your EMS agency is multiplied by the number of miles incurred for that particular transport and added to the Base Rate to tally a final reimbursement amount that is sought for payment.

“Other”

For simplicity sake, we lump any service provided and billed for into a catch-all category or “Other” bucket.

Some EMS agencies choose to break out certain adjunct charges which may or may not be paid as a separate line item. Once again, CMS/Medicare sets the tone for this about 15 years ago when they mandated what was then called a “Method 2” model for billing. The Method 2 model directed that Medicare would only pay for the Base Rate level of service and a corresponding Mileage charge.

EMS agencies can choose to “roll” the “Other” charges together to form a hybrid base rate, but no line items other than the Base Rate and Mileage charges would be paid on a claim by Medicare. Many other payers followed suit.

We do, at times, still find some commercial payers that pay individual itemized charges on the ambulance bill as outlined in a participation agreement, but this is not the norm.

The “Other” category can include a myriad of charges for equipment or services. For example some “Other” charges may represent attempts to collect reimbursement for Oxygen (delivery supplies), medications, or any number of other additional services or supplies.

Cost Data Collection on the Horizon for EMS

2018-02-23T13:40:00.000-05:00

Reality Time

When the Philadelphia Eagles won their very first Super Bowl two weeks ago, the City of Brotherly Love went giddy wild. There were light poles to climb, banners to wave and confetti to throw.

Then…it was reality time.

All that confetti had to be cleaned-up, the banners folded and tucked away in the attic and the reality that football season was over hit (along with the hangovers…dilly, dilly.)

That’s where we all are at now that the Medicare Add-On payments have been extended by Congress for the next five years.

It was a big victory. Finally!

But now it’s reality time for the ambulance industry as we face a new initiative.

Cost Reporting

When President Trump signed the Bipartisan Budget Act of 2018 into law on February 9^th, we all breathed a sigh of relief. But the “fine print” of the law will now usher in a Congressionally-mandated provision requiring the Centers for Medicare and Medicaid Services (CMS) to begin working toward the process of collecting cost data from the ambulance industry.

We all know that whenever the “Feds” mandate anything new that it translates into something that will require more work on our end. This is just inherent in the whole Medicare circle.

However, our industry should tune our brains to how this mandate may just be the golden cow that we have all sought after for some time. The American Ambulance Association put it best this week when they disseminated a communication penned by Kathy Lester of Lester Health Law PLLC.

Lester explains that the cost data collection system that is proposed will allow “…the federal government to collect meaningful data that can be used to address the inadequate reimbursement rates and modernize Medicare ambulance payment policies.”

We agree in principle, if this is the true intent. If this plays out, then the requirement will become a very good thing.

We surmise that the entire American ambulance industry will collectively agree that we can’t continue to work toward brinkmanship every so many years, biting our nails over potentially losing dollars. Plus, the politics needs to be removed from the process and a system that makes sense, based on true facts and figures, be instituted to drive reimbursement levels that adequately fund EMS for the future.

Timeline

There is no need to panic as this new cost reporting requirement is not going to happen overnight. In fact, the plan as detailed by the AAA shows that the full implementation of the system will span out over several years into the future.

The very system to be devised to collect this cost data will not even begin to be built until sometime in 2019. The new bill mandates that there be discussions to include the ambulance industry on how and what data is collected in 2019. Basically there will be no end-user effect for this entire current year in 2018.

Throughout 2019 while the vehicle to gather the data is devised CMS will also identify which providers and suppliers will make up the representative sample that is required within the legislation. Data will then be collected using this new collection vehicle beginning in the years 2020 through 2024. CMS will issue the requests during that 4-year span.

To add some teeth to the mandate, in 2022 there will begin to be a penalty assessed against those ambulance providers and suppliers who are asked to submit data but have not done so to the satisfaction of CMS. At that point, those who fail to meet the requirement will be assessed a 10 percent payment reduction in the year thereafter.

Congress will then review the data collected over that 4-year span after which there will certainly be more discussion regarding the results and how they will affect future reimbursement policies.

The current blueprints for the program call for data collection to happen no less than an every 3-year cycle.

It will be interesting…

It will be interesting come 2022 (or 2023 depending on when the clock begins to tick given the late passage of the extension legislation) what Congress will do when once again faced with the question of extending the Add-Ons. The cost data collection process will not have completely played out by the time the current extension period draws to a close. Plus, we know that the proposed Medicare Payment Advisory Commission (MedPAC) report detailing to Congress the cost collection findings will barely be published in 2023, let alone have been fully reviewed for its relevance and to allow time for a permanent fix.

Will Congress once again extend the Add-Ons or will they hold back to await the final analysis of the data that has been collected via the newly mandated process? If only we could see the future!

Clear. Clinical. Documentation.

2018-02-16T12:15:00.000-05:00

Bloggers note- we posted this blog almost a year ago to the day. It’s one of those topics that never gets old and the information remains as important as it was the first day we posted it. All of us must keep this important concept in mind when documenting our EMS transports. I hope you enjoy reading it again (or for some of you for the first time!)

CMS

Three words with impactful meaning anchor our discussion today. The Center for Medicare and Medicaid Services (CMS) sets the definition of medical necessity of an ambulance patient that all of us in the ambulance billing industry strictly adhere to.

The definition centers on the clinical requirement “where the use of other methods of transportation is contraindicated by the individual’s condition.” The direction we receive from “The Feds” includes the warning that EMS Patient Care Reports (PCRs) must include clear clinical documentation detailing the ambulance transport incident verifying that the patient truly met the clinical requirement.

Thus, once explained in the PCR, Medicare, Medicaid and most other insurance payers will reimburse the claim that your billing office submits for payment to cover the costs for you to provide an EMS service to your patient.

So let’s quickly breakdown our three key words.

Clear

The word clear is used as an adjective, adverb or verb. The overriding definition in the dictionary defines the word as denoting transparency or defining something as easy to perceive, understand or interpret leaving no doubt or ambiguity.

The medical necessity definition uses it as an adjective. So, clear clinical documentation calls for the documentation in your PCR to be easily interpretive to describe your patient’s medical necessity leaving no doubt or ambiguity that other methods of transportation were contraindicated (or not) for your patient given the condition they were in at the time of the transport.

It’s a very simple concept when you think about it and yet we, in EMS, struggle with it because many of us are just not good with words.

Remember your PCR does not have to be a best-selling novel, but the words in your PCR must be precise and clearly demonstrate why there was no other way to transport your patient without endangering or further exacerbating the patient’s medical condition.

If there were another way to transport the patient without further endangerment of your patient, then the decision can be made based on the clarity you’ve written into your PCR as to whether it is best to bill to the insurance payer or direct to the patient.

Clinical

Something is clinical when it coincides with and involves the actual observation and treatment of a patient. Of course we know that payment for ambulance is based on transportation but observation and treatment happens in the transporting ambulance, so the two go together.

This is where the focus of your documentation is placed.

When we are directed to support medical claim billing for ambulance transports by providing clear clinical documentation in the PCR, the clinical part calls for EMS providers to document that observation and treatment in such detail that it paints a picture in words regarding everything that happened on the scene, in the ambulance during transport and upon arrival at the facility leading to patient transfer.

Clinical is objective. Clinical involves numbers, readings and interpretations such as vitals with numeric values, readings from medical instruments in the ambulance with accompanied objective and scientific interpretations of the instruments’ values. The result is written statements about the patient’s medical condition such that the reader of your documentation clearly has a laser view into the patient’s condition in that moment of time.

It’s clear that the authors of the ambulance medical necessity definition were anticipating that every single ambulance transport that is billed for reimbursement will be supported by a PCR that is written in adequate detail to spell out the clinical relevance of the incident.

Documentation

And finally after two adjectives, we arrive at the noun to anchor the phrase.

Documentation is official information and/or evidence that comprises a record of an event or happening. We use documentation to classify (such as choosing a procedure code to denote the ambulance level of care- ie. Emergency vs. Non-Emergency, ALS vs. BLS, etc.)

We also use documentation to support the all-important ICD-10 diagnosis code that spells out the patient’s condition at the time of transport. Here text is primarily used to describe the patient’s condition and chisel in time the definitive historical clinical record of this one ambulance event.

Because the documentation is clear and clinical, the reader will be able to review the PCR and gain a full understanding of why this patient, in this moment of time used the ambulance for transport from one place to another in either an emergency or routine non-emergency event.

Congressional Victory- Medicare Add-Ons Receive New Life!

2018-02-09T10:50:00.001-05:00

Minutes Ago…

We’re writing this piece on the morning of Friday, February 9, 2018. Remember this day, as just minutes ago the United States Congress passed a bill to keep the government’s doors open for another month and with it they passed important provisions affecting the ambulance industry.

Literally hours after Congress approved the measure, the President signed it into law.

Congress just passed a 5-year extension of the Medicare ambulance add-on payments!

The American Ambulance Association issued a quick notice to the industry celebrating this passage which was part of a two-year budget deal reached by congressional leaders and finally passed by the Senate early this morning and ratified by a favorable vote in the House of Representatives soon thereafter.

Add-Ons

By now, most everyone recalls that over fifteen years ago it was determined that the Medicare National Ambulance Fee Schedule was underfunding the ambulance industry by a pretty wide margin. At the time, Congress decided to put in place a “temporary” stop-gap measure that amounted to an add-on payment factor of +2% for urban area reimbursements, +3% in rural areas and +22.6% in the most remote geographical areas designated as super-rural. Additionally, in the rural and super-rural areas per mile reimbursements were increased by an additional 50% for the first 17 loaded mileage of each transport.

The catch was that each year these add-ons had to be renewed by Congress. After a while, Congress extended the add-ons for a period of multiple years with the last extension expiring on December 31, 2017 with no action to extend decided by Congress prior to expiration of the current term.

Lobbying groups like the AAA pushed hard for the reinstatement of the add-ons and finally, today, those efforts paid off. The industry anticipates that these add-ons will be made retroactive back to January 1^st and applied to payments moving forward.

In Exchange

In exchange for conceding a 5-year extension which costs additional Medicare dollars, Congress placed some future conditions on releasing the purse strings.

Cost Data Collection

This was inevitable.

Congress needs to be supplied proof that we deserve these extra dollars. So, for the first time in our history, the ambulance industry will be required to submit periodic Cost Data reports to CMS.

The good news is that the ambulance industry will have direct input on the structure and implementation of the Cost Data report. This is a concession brokered by the AAA so there is input from our side. Congress is requiring this so there is an “appropriate balance” between obtaining useful data without overburdening or “onerously penalizing” ambulance services.

However, it is written into the provision that there will be a 10% reimbursement deduction penalty assessed in each year following an ambulance service’s failure to report cost data when requested. This is considerably a better option than the original plan of taking payments back or an outright withholding of payments which was on the table in the first draft of the legislation.

Additional Cuts in Dialysis Transports

In order to pay for the extension, Congress will assess an addition 13% reimbursement deduction to non-emergent dialysis transports. Again, this is a reduction from the 22% proposal in the first draft.

Of course, this adds the 10% reduction from a few years ago that is already in place.

While unfortunate, we all know that dialysis transports are continually on the radar screen for the Feds and the target of many a fraud and abuse investigation. So, it comes as no surprise that this provision rides in on the coattails of the extension legislation.

President Signed Immediately!

Literally hours after Congress approved the measure, the President signed it into law. Now, some administrative formalities will take place in order to implement the changes. We hope to see CMS release a Public Use File (PUF) listing the new reimbursement fee schedule in the days coming.

The “Face” of Your EMS

2018-02-02T10:44:00.001-05:00

“Face?”

Whether you realize it or not, the EMS agency you serve has a face and it’s you!

It’s the impression that is left behind in the eyes of the patient, his/her family and/or the people that surround him including, by extension, facility staff and those in the overall care loop.

Your EMS agency’s face is very important as it ultimately becomes how it represents and labels you to the patients in the communities you serve.

Let’s take a look at the three areas that make up our EMS agency footprint.

Intake/Front End

The very first encounter outsiders have with your agency is when the phone rings, so the call intake portion at the front end of your process is extremely important for setting the tone of what your agency’s customer service face looks like.

If your agency is a 9-1-1 provider, this is beyond your control- or is it?

As an administrator, have you met recently with the persons in charge at the 9-1-1 center to take a look at what they do for you? Sometimes simple dialogue can help each side understand each other better, plus it opens up channels for you to examine how your agency is being represented to the public.

If your agency handles routine, non-emergency transports it’s likely you maintain a separate call intake resource outside of the 9-1-1 system. Here’s where your agency’s customer service face is crucial.

Not only does call intake drive your agency by pulling in work on any given day, but the encounter experienced by the patient and the facilities you serve may dictate whether or not your agency is used by the referral source for future transports.

Plus, your call intake staff helps with all phases of the transport scenarios by obtaining vital information that is helpful to your street staff all the way through the back end of your process, flowing to the billing office and collection success.

Street Presence- Reacting and Interacting

Administrators… How are your crew members representing your agency? Do you know?

EMS providers… How are you representing your agency? Do you care?

Notice we’re addressing two groups of people here. It’s important that as an administrator, you have boots on the ground in some form in order to have a handle on how your crews represent your agency out there where it happens.

As EMS providers, you and your partner must remember that your agency’s reputation and ultimately your reputation rests on your shoulders and how the patient public sees you react and interact.

How do you look today? What are you saying today? If you love your job, show it by treating people with the same caring mannerisms you’d want someone to treat you with if you were the one lying on the stretcher.

If you hate your job, find another one.

Closing the Loop- The Back End

The run’s completed and your patient has been delivered to his/her destination.

How is your agency represented by the office, following the run? Specifically, since this is a blog centering on EMS billing; how is your agency represented by the billing office?

Whether your agency maintains its own hired staff for billing or you use an outsourcing agent for the task, once again the “face” the patient will remember will be that of the person who answers the phone and guides your patient through the revenue recovery cycle.

Staff members who practice good phone etiquette and are trained in being professional and courteous will win the day for you. As an EMS billing outsource company, we argue that professional customer service trained individuals who do nothing but this all day long can be the consistent positive face for you. These people must be adept at problem resolution, have a high level of compassion and knowledge and understand all phases of EMS billing.

The Right Step

Now it’s time to take some steps to adjust your agency’s face. Do the following…

Review- take a good look at your EMS agency’s face at all levels.
Analyze- identify the good faces and the not-so-good faces of your organization. Survey, ask your patients questions, test and measure
Act- excise the parts of your face that are less than positive, replace and retool where possible but also reinforce the areas that are working.

Consider outsourcing and consulting- there’s someone out there that can give you a softer and more effective face!

The Power of a Beginner’s Mindset

2018-01-26T11:11:00.000-05:00

This week…

This week several of us in the billing office had the pleasure of taking a day to re-evaluate our leadership skills.

Business coach Jim Riviello of Leadership X University, author and business motivator, spent a memorable day with us as we examined our impact on the EMS billing industry basically from the inside out.

Part of our day centered on approaching our duties from a beginner’s mindset.

What if it isn’t?

If you are open to new ideas then you most likely have harnessed the power of the beginner’s mindset. Think back to when you were brand new to EMS and how your mind was asking questions every 5 seconds.

But now that you are not a chronological beginner, are you a mental beginner? If you have the beginner’s mindset then you’ll be eager to re-think every single process you own.

What you have been taught to believe may be true- but WHAT IF IT ISN’T?

As we worked through applying this to our EMS billing world, the concept not only relates to the office but also to many aspects of this life-saving thing that we do on the outside in the field, too.

We encounter people we work with all the time that are dug in and very much a creature of habit- even to the point of protecting processes just for the sake of protecting them. We all know that in EMS in order to be effective we must continually question our practices and the things we do every day.

Had we not questioned the things we do over the course of many years, we’d all be running around in a Cadillac with nothing more than a scoop stretcher and an oxygen tank.

The same holds true inside, too.

There’s no way that we can navigate the EMS billing world using the same tactics and routines of even just a few years ago. Times change and we must adhere to the following steps in everything that we do in EMS.

Ask More Questions

Think about it, asking questions is at the center of EMS.

If you are good fashioning effective questions then you’ll be good at assessing your patient, good at treating your patient, and by extension good at documenting your run effectively too.

Then the EMS agency you serve will be well-served.

Foster an environment within your EMS agency where asking questions are center to the culture. Stale ideas and the inability to ultimately change will torpedo our systems.

I think our billing office is really good at asking questions. Is your’s?

We look to test, measure and tear it all apart if needed because we must serve our clients and the communities they serve in order to bring in every dollar to save the next patient’s life.

Welcome and Embrace Change

When ICD-10 was mandated on October 1, 2015, few billing offices (ours included) were doing anything but “embracing” change. We all were grumbling and fiddling with our billing systems to accommodate the new mandate.

We made it happen because we had to make it happen. But embrace it? Probably not and simply because it was CHANGE (big change!)

Two years later this is the one example that still sticks in our heads because it was personally painful. Change often is painful, but then again so rewarding.

To embrace change is to welcome it. To embrace change is to promote it, teach it, let it grow and weave like a vine into every thread of your EMS agency’s culture…from the street to the office.

The opposite of embracing change is fearing change. When the fear of change invades an organization, like a cancer it chokes off the life of that organization. No one is motivated to find new answers. The same old thing is done day-in and day-out. Performance suffers and morale dips.

Ultimately not much energy flows. Only entropy reigns.

Open to Help and Assistance

We all must continually learn each day.

Our office is learning all the time.

We achieve better results when we share our thinking.

EMS is a team effort.

The providers can’t do their jobs without the mechanic that keeps the truck running. The administration can’t manage the organization without the insights and respect of the people that make up the system.

The billing office can’t bill without precise, detailed documentation from the providers. Likewise if the billing office doesn’t do everything in its power to bring in the biggest buck, then the street providers won’t be paid and the equipment will become dated and ineffective.

Release Past Limiting Beliefs

You must empower yourself and others in your organization to help you create the future of EMS, rather than to hang onto the “glory days” of the past.

So when the billing office asks everyone to get together for some documentation training, be available to join in the discussion. Likewise, if your billing office is demanding things from you that you know will not serve the organization well, then ask the question Why?

Approach your EMS world like you did when you were a beginner and you’ll be surprised at the potential you uncover!

Medicare vs. Medicaid- What’s the Difference? (Part II)

2018-01-19T11:37:00.001-05:00

Medicaid

Welcome to Part II of our two-week series pointing out the differences between the Medicare and Medicaid programs in the United States and the affect each program has on EMS and how that effect differs.

This week we are focusing on Medicaid or in some areas called Medical Assistance.

Title XIX

Medicaid in America was authorized by Title XIX of the Social Security Act and signed into law in 1965 alongside Medicare. While Medicare was intended to provide health coverage for the elderly or disabled, Medicaid was incepted to provide coverage for low income individuals.

All States, the District of Columbia and the United States Territories offer some form of Medicaid. The Federal Government establishes the parameters and each State administers the program.

ACA Expands Medicaid

In 2014, the Affordable Care Act gave authority for the expansion of Medicaid. The expansion now meant that individuals under the age of 65 and families below 133% of the Federal Poverty Level (FPL) were made eligible to participate in the program as well as standardizing CHIP rules for eligibility and providing benefits.

Companion Programs

In addition to Medicaid, the Children’s Health Insurance Program (CHIP) and the Basic Health Program (BHP) are also available to low-income individuals.

CHIP covers children’s health benefits for families whose income is too high for Medicaid up to 200% of the Federal Poverty Level. Additionally the Basic Health Program (BHP) provides health coverage for low income families whose income fluctuates high and low at times.

The Effect

The effect of the Medicaid program can be substantial on EMS systems and the reimbursement that they receive for transports of Medicaid, CHIP and BHP covered patients.

Medicaid payments in many States are absolutely horrible for all services but especially for ambulance transportation. In most States the reimbursement level for ambulance is so grossly underfunded that it’s almost a laugh at times. Plus, many States refuse to pay or follow narrow guidelines for ambulance claims adjudication.

Medicaid eligible patients are a protected class which locks the ambulance service into accepting sub-par reimbursement levels that rarely come close to covering the costs to provide EMS services to these patients.

There are those people we refer to as the “dual eligibles” of age and income level to qualify for Medicare based on their age and Medicaid based on their low income. Many states will not cover the 20% co-pay for Medicare Fee-for-Service and the EMS agency is stuck accepting only the 80% of the Medicare fee schedule for that area with the inability to collect the remaining 20%, given that the patient has no monetary resource to pay the bill.

When the economy is bad…

Over the years, this billing office has seen the lasting effects of a lagging American economy on the bottom line.

People lose their jobs because their place of employment shuts down and in order to protect themselves with health coverage they join the Medicaid ranks. Former President Obama also worked hard to expand the Medicaid program which meant that many times our billing office has reviewed client accounts whose volume of Medicaid patients now accounts for a much larger percentage of the organization’s payer mix, some increasing by nearly double over a few years.

And, this trend then equates to similar or even increased call volume, not followed proportionately by equal revenue increases. Plus, given the nature of our mission and unlike some other healthcare providers, EMS agencies do not have the luxury of refusing to serve Medicaid patients.

Providing the same services at the same cost to patients for less money than we receive from other payers while all the time the Medicaid payer section as a percentage is sometimes doubling, is a difficult balancing act for EMS agency administrators trying desperately to balance their budgets.

Medicare vs Medicaid- What’s the Difference?

2018-01-12T10:53:00.000-05:00

Interchangeable?

It seems that often EMS people like to interchange the words Medicare and Medicaid. While similar in scope, the reality is these programs are two uniquely different government offerings.

We thought it would be helpful to define the two programs and call attention to their similarities and differences.

This week we’ll dig into Medicare. Next week, we’ll explain Medicaid complete with the effects on ambulance payments by both programs.

But first…

But first, let’s retrace the history of the programs.

President Harry Truman first floated the idea of a comprehensive government health insurance program in 1945, however he was unable to convince Congress to take his vision anywhere.

Two decades later, President Johnson mapped out his “Great Society” vision for America and was able to push through a new program to cover older Americans using Medicare and Americans of low income under Medicaid.

The programs have been expanded and re-written a time or two over the years, but the same basic concepts and structure exists at the bedrock of the initiatives now 53 years later.

Medicare Defined

Medicare is a program designed to benefit persons who have reached retirement age. It also covers those with long-term disabilities that keep them from working and thus affording health insurance.

It should be noted that when a patient has Medicare, there are a number of options and we will explain that briefly below. Additionally, a person may fit into what’s called Dual Enrollment status where the patient is eligible for both Medicare and Medicaid coverage.

The Medicare Alphabet

Medicare has four parts and all parts are identified alphabetically using the letter A through D.

Medicare Part A- This is hospital insurance. This part of the program covers medically necessary hospital inpatient stays, skilled nursing facility stays, home health and hospice. Some hospital EMS systems have been granted permission to bill Medicare Part A for their transports, as well.
Medicare Part B- Part B is the medical insurance portion and pays using what we call Fee-for-Service Medicare covering doctors services, preventive care, durable medical supplies, hospital outpatient services, laboratory test, x-ray service, mental health and, of course, medically necessary ambulance transportation. Medicare Part B is primarily where the payment for ambulance services resides.
Medicare Part C- This is the private health insurance leg of the program. Private health insurance plans- HMOs and PPOs also called Medicare Advantage Plans are rolled into this part. These private plans must cover what original Medicare covers but can impose different payment rules, costs, coverage restrictions, etc. Many times, Medicare Part C also incorporates Part D into their offerings for a one-stop shopping solution.
Medicare Part D- Part D is the outpatient prescription drug coverage program. These benefits are never direct from the government and are always administered and paid by private contractors. This part has no connection to EMS in any way.

Private Contractors

Speaking of private contractors, Medicare and Medicaid is administered under the United States Department of Health and Human Services (HHS) within the regulatory arm of the Centers for Medicare and Medicaid Services (CMS). Companies called Medicare Administrative Contractors (MACs) contract with CMS to cover geographically connected Jurisdictions which are groups of States, typically contiguous States, forming a physical jurisdiction. The MACs process incoming claims and reimburse on those claims.

Fee Schedule

For ambulance, a national Medicare Ambulance Fee Schedule incepted in 2002 is adjusted each year by a formula called the Ambulance Inflation Factor (AIF) which controls the reimbursement levels. The fee schedules are calculated at the base by geography using Geographical Practice Cost Indices (GPCIs) which factor in account area economic trends. Because it was determined the Fee Schedule underfunds EMS, the reimbursement levels have been bolstered by what are called the Bonus Payments of 2% in urban areas, 3% in rural areas and 22.6% in small geographic pockets called super rural areas. Rural and super rural areas also receive a 50% increase in the mileage payment per loaded mile for the first 17 miles of each and every transport. The bonus payments expired on December 31, 2017 but will hopefully be renewed later this month when Congress re-convenes after their holiday recess.

Transport Benefit

It is important to note that Medicare benefits are only paid when a patient is transported in the ambulance. Ambulance suppliers and providers must accept the fee schedule payment, as payment in full and can only balance bill the patient for either the 20% amount that Fee-for-Service Medicare does not pay direct, citing a cost-sharing requirement, or either a deductible or co-pay amount assessed by a Medicare Part C insurer.

Winter Flu Season- How to Document?

2018-01-05T12:53:00.001-05:00

Holidays Behind Us…Enter Flu Season

We trust that you had a wonderful holiday season filled with many WARM memories (and we emphasize WARM!)

We’re back to our normal routine so let’s dig into a direct documentation topic…. How to document transports that are initiated either directly or indirectly due to the effects of influenza.

Winter and the Flu Bug

It’s winter. Especially for those clients we serve what is fast becoming one of the coldest most brutal winters in history, flu season ushers in a whole new set of treatment and transportation possibilities. Since this is a blog about all things ambulance billing, let’s take a minute to think about how we can effectively document when we transport persons affected by the flu bug.

Do flu patients need an ambulance?

That’s a good question!

On the surface and in contrast to the many severe emergencies we all handle on a regular basis, we seem to think about influenza as being not so bad. But think again.

According to government’s Centers for Disease Control and Prevention, influenza activity increased sharply for the week of December 24th to 30th equating to a cumulative rate of 13.7 laboratory-confirmed influenza-association hospitalizations per 100,000 population.

Sadly, 26 pediatric deaths were recorded in the U.S. from just October 1st through December 31st. The CDC provides an annual estimate for adults as there are a myriad of complications that cannot be held directly related to flu as in pediatric patients, but the estimate for 2017 will see a potential high off 56,000 deaths due to flu occur out of a range of 9.2 million to 35.6 million influenza cases for the season.

So, the answer to our question is given the data...maybe.

The Facts

To get started with the documentation discussion, we remind all of you that we must describe the patient’s medical condition in sufficient detail to indicate why transportation by any other means other than an ambulance vehicle was contraindicated for your patient.

Your task is to describe the patient’s condition in full, including your assessments and the numbers and values derived from that assessment.

Since the older members of our patient population are often found by us in some kind of extended care facility, it is also important to document why the patient could not be adequately treated for influenza-associated signs and symptoms at the facility.

In short, was the trip reasonable in nature?

Documenting the Hands-On “Stuff”

So let’s brainstorm all the “stuff” we’ll see connected to flu patients and how we can document it all.

Respiratory Complications

Of course, with a fair amount of flu patients the influenza morphs into a respiratory situation sometimes resulting in the patient’s contracting pneumonia. For the oldest and the youngest of our patient population, this can be a life-threatening event.

So naturally we can think of our need to document…

Lung sounds (for patients in extended care facilities, we must also document how our treatment was needed beyond the treatment that cannot be provided at the facility)
Pulse-Oximeter Readings
Oxygen Delivery (delivery rates, delivery device, treatments- medications by inhalation, injection, infusion)
Need for suctioning
Use of positive pressure devices
Coughing and sputum observations

Dehydration and Fevers

If dehydration or even possible sepsis is a factor as an extension of the flu condition, then consider documenting things like…

Skin assessments – color, texture, feel (warm, hot, cold, etc.)
Severely elevated body temperature readings

Nausea/Vomiting/Diarrhea

What if nausea, vomiting and or diarrhea are part of your scenario? Then include findings such as…

Duration/Onset
Color and consistency of the solids and/or fluids expelled
Volume expelled compared to fluid intake as verbalized by the patient or someone in the know

Compromises and Secondary Systems Involvement

Does your patient have a chronic underlying condition that the flu now is exacerbating? If so, be sure to document those complications. There are times when we focus so much on the apparent that we can forget to include the spillover affect into other areas.

So, if there is any secondary compromise such as cardiac or general systems compromise, be sure to include those findings in your Patient Care Report.

What did the cardiac monitor tell you about your patient?
Was there any kind of neurological compromise that is negatively affecting your patient?
What did you do to counteract the negative secondary symptoms?

The Basics

Naturally, never forget the basics.

Always document…

Vital signs
GCS
Level of Conscious
Mental Status that varies from the patient’s baseline
Result of critical labs prior to EMS activation (however, negative values alone, minus signs and symptoms of a serious illness event will not constitute justification for payment)
Any associated pain (include a pain rating on a 1-10 scale, as you normally would do)

Medicare Bonus Payments Expire- What’s Next?

2017-12-29T10:34:00.000-05:00

December 31, 2017, 2359 Hours…

When the New Years ball begins its drop in New York City on December 31, 2017 at 2359 hours, so will the Medicare Fee Schedule Bonus Payments drop.

Those of you who operate in urban zip codes will see 2% less, rural zip codes 3% less and super rural services less 22.6% plus everyone in the rural and super rural areas will see 50% less mileage reimbursement for the first 17 miles of each trip.

Now before you all suffer the “big one,” all of this appears to be temporary.

How temporary? Well…we’re not sure.

January 19

According to an advisory sent out by the American Ambulance Association (AAA) to all of its members nationwide, there remains strong bipartisan support for reinstating the bonus payment extenders when Congress returns from the holiday recess next month. The anticipation is that the extensions will be added to the next government funding legislation which must be passed by January 19th in order for the Federal government to keep their doors open.

Unfortunately, Congress was too busy slapping each other on their backs over passing tax reform and failed to take up the extensions prior to the Christmas break. Of course, we all find that somewhat disturbing but then again we’re sure you’ll agree that this is no surprise to any of us who have monitored the progress of these issues for many years.

Be Proactive!

So, where are we? The fact is, the bonuses will lapse and the reality is reimbursement will potentially drop. There’s nothing anyone can do about it at this point other than ring the phone and the e-mail inbox of your district’s Federal legislators to remind them that you and your vote are watching what they do in support (or failure to support) extending these EMS payments.

Be proactive!

In addition to lobbying Congress, make a plan.

Many of our clients hold claims in the New Year for several weeks in an attempt to side-step getting hit with the annual deductible. Especially those ambulance services that legally conduct a subscription or club type program follow this course of action. Beyond the deductible consideration this year, is the strategy of holding claims until Congress has time to act on the bonus payments to avoid being paid a lesser amount initially requiring a retroactive payment adjustment following Congressional action on the matter, later on.

Of course, when considering putting a hold on 2018 Medicare claims, each EMS agency must factor in the cash flow hit to your short-term bottom line. If your agency does not have the wherewithal to accommodate such a hit, then it may not be a wise move. But, if you’ve put some money away for the proverbial rainy day, then now may just be the time to operate off some of the reserves with the intent to replace the nest egg when all of this has been fixed.

CMS May Force Things

Being prepared may just be something you want to think about anyway. CMS may just force the issue and may ask their Medicare Administrative Contractors (MACs) to hold paying claims as they did in 2014 when they found errors in the final fee schedule that year.

The AAA astutely points out that paying and fixing claims retroactively is expensive, so it will be interesting to see how they handle this situation. Will they pay the claims and then expect us to re-submit for additional payment or will they instruct the MACs to automatically reprocess claims for additional payment?

Either way, for all of us in the billing office it creates a bit of a mess for those in posting…plus, those of you who base your gross charges in some formula based on the Medicare approvals are further in limbo. And…then there’s the issue of reports not reflecting any reliable reimbursement expectation for budgeting and forecasting purposes.

Mini-Rant…

We close this discussion with a mini-rant.

We don’t know about you but this office is plum tired of the ambulance industry in the United States being an afterthought. Federal emergency planners talk all the time about the vital role of Fire/EMS and First Responder resources in disaster and mass casualty/terrorism preparedness. Yet when it comes to funding, we wish the same amount of urgency would be recognized by the real decision-makers in Congress.

To underfund EMS, even for a fraction of time, is unacceptable. Someone in Washington D.C. needs to wake up and see America’s Fire/EMS front lines in a clear perspective when it comes to funding.

We’ll put that on our New Year’s wish list!

“NICE” by Default

2017-12-22T12:16:00.001-05:00

Naughty or Nice?

It’s that time of year when we all wonder where we fall on ol’ Saint Nick’s magic list.

Where do you stand? Will a big old lump of coal hit your stocking or will Santa hit your chimney with a whole bunch of toys?

It’s the stuff we have all lay awake and think about since we were all knee high to a grasshopper. Nervously as visions of sugarplums dance around in our heads, we listen for the pitter-patter of hoof prints on the roof of the station…that is just before our dreams are interrupted by the chirp of a Minitor accompanied by the rude awakening blast of a claxon chiming out our next adventure.

Gotta tell you…

Gotta tell you, in our humble opinion and we know Santa pretty well (like our pipeline to insurances, we tap into the North Pole’s database pretty regularly), the Jolly Old Elf has pretty high regard for all of you in Fire/EMS.

Of course, it has a lot to do with that night a few years ago when the sleigh crash landed in the middle of The Heartland during a hellacious snowstorm a few years back and some of you were there to save Christmas, but literally Santa has blinders on when it comes you all of you in the field.

Sure…it wasn’t easy overlooking that incident from the Christmas party of 2015. The Elves all thought there was a “naughty” future for a few of you that time, but the buck stops with Santa himself and he squashed the effort to put a checkmark for you in that column because, well…it’s you.

You get a pass!

Santa has a soft spot in his heart for all of you First Responders because Santa loves when people love on other people.

You get a pass!

Love on people is what you do 24/7/365. When people are at their worst, in their darkest most desperate hours, it’s you they turn to.

When even our best resuscitation efforts cannot save the day, it’s you people lean on, cry on, look to as their first line of comfort. When Granny Smith falls in the middle of the night and she hits her “button,” it’s your smiling face and strong arms she relies on to get her re-nestled all snugly in her bed.

Even when lonely Mr. Jones calls 9-1-1 basically just to see a smiling face that assures him that all is right with the world and he’s going to live another day…you are that one person who he will receive a warm word of encouragement from.

When Sally crashed her Honda in the big snowstorm while her husband was on business in Walla Walla Washington and you held her hand to let her know everything was going to be okay…Santa’s magic snow globe replayed the video for him to see firsthand how caring you can be.

And so…

And so…it was never an issue for Santa when your name popped up on the screen.

“That one belongs in the “NICE” column,” he exclaimed.

For making the world a better place in the midst of the storm of life, the guy in the red suit has your back. Now be nice and be safe and party responsibly for sure…just know that the guy from the North Pole has a default for you and “NAUGHTY” you will never be (that is unless you elect to be- then that’s up to you <wink…wink> !!!)

From this billing office to all of you out there on the street doing the EMS thing that you do…Have a wonderful holiday with a big thanks from all of us for just being YOU!