By Daniel J. Pedersen, Esq.
In many EMS operations, there are three unique and distinct divisions:
- Call intake/dispatch,
- Operations, and
- Billing/reimbursement.
I routinely refer to these as three legs of a stool, with the top surface the entire EMS operation. Pull any leg out, and the entire operation falls apart. While some might view these as three separate components of the EMS operation, they are, in fact, intertwined, and need to rely on one another for the entire EMS operation to function.
Crews need to rely on getting information from call intake/dispatch to know where to go and what to expect. In the same respect, billing/reimbursement relies heavily on crew documentation in order to make appropriate billing decisions. All three legs of the stool need to work in harmony 鈥� they are not separate components, but integral team members.
The primary role of the EMS crew is to provide patient care. Patient care, however, comes in many forms: clinical, legal and financial, to name a few.
- Clinical care is comprised of the hands-on services rendered to the patients. Helping people is what most EMTs and medics are interested in doing. This is perhaps the most obvious of the various roles of the EMS crewmember. After all, the ambulance crew provides prehospital care.
- Legal care is the paperwork. As health care providers, the EMS service providers need to document what they do (and don鈥檛 do), not only to protect themselves, but also to protect the interests of the patient. The EMS charts are medical records which must be accurately and properly preserved. This is no different than doctors and nurses taking notes and charting patient conditions at a routine appointment, ED visit or at a long-term care facility. As health care providers, documenting the care provided is simply part of the job.
- Financial care is taking the steps to ensure proper billing decisions are made, so that the patient is not financially harmed. Does the patient have insurance, and if so, has the crew documented insurance information? Is the service something that the patient might be financially responsible for, and if so, is the patient aware of that fact? Is the service something that a facility is financially responsible for, and if so, is there adequate information about the nature of the patient鈥檚 condition and inpatient status to allow a biller to decipher who to bill?
Incomplete EMS documentation can lead to billing errors
One classic example of where incomplete or inaccurate crew documentation can lead to billing problems is with hospice patients. When a Medicare patient has a terminal illness and elects the Medicare hospice benefit, financial liability for an ambulance transport becomes complex. In order for billers and coders to make proper billing decisions, they need to know nuanced information about the patient, and this hospice condition. In fact, some of this important hospice information can be obtained at the time of call intake 鈥� again, showing how all three components of the EMS operation plan a role in the entire success (or failure) of the organization.
Call intake can ask questions about the patient鈥檚:
- Insurance,
- Condition,
- Facility inpatient status (i.e., SNF Part A), and,
- In the case of hospice patients, the terminal illness,
- Whether hospice was elected, and
- Whether the transport in question is related, or unrelated to the terminal illness.
Crewmembers can also work to obtain similar information from the patient, facility representatives or family members present on the scene. Having this information facilitates the billing function, to allow for prompt billing, and proper payment from the right payer.
If adequate (and appropriate) information is not obtained about basic facts (like the patient鈥檚 hospice status), inappropriate billing decisions can be made. This can lead to post-payment audits, or other investigations by government entities. These investigations can have a chilling effect on the sustainability of the organization as a whole.
Improperly billed claims (due in part to poor documentation) can trigger audits, where extrapolation is used, and the government stakes a claim to a six or seven-figure overpayment demand. Most ambulance services 鈥� especially volunteer, small municipal or private organizations 鈥� cannot afford to pay such exorbitant refunds.
The hospice example is just one situation where tiny details play a significant role in the overall billing of a transport. Unfortunately, ambulance billing is not as simple as getting a prescription filed, or seeing a doctor for an ailment. The mere fact that the ambulance transport occurred does NOT mean insurance pays.
EMS billing rules
There are a wide variety of Medicare (and other payer) rules that must be followed, and billing decisions are made based on the quality of information gleaned from call intake and crew documentation. Where that documentation fails or is incomplete, so too does the billing decision.
Except for the handful of volunteer or municipal based entities that do not bill, the billing department is the lifeblood of the organization. In this day of Medicare audits and scrutiny into compliance with all federal and state laws government health care, ambulance services cannot afford to feed the billing department incomplete, inaccurate or misrepresented information. Otherwise, the entire operation falls apart.
This article, originally published on Nov. 7, 2017, has been updated.
