Billing ambulance trips is difficult and not always rewarding. Yet reimbursement revenue is the lifeblood of EMS organizations. We already know billing is hard to do, but have you ever thought about how much it costs to collect a bill? Harvard Business School and Duke University got together to find the answer to that question. Let’s discuss what they found, and we will provide some ideas that will help with your costs of billing.


The researchers conducted interviews and mapped the whole billing process. Their results were eye-opening. Can you imagine - $99,000 to collect the bills of one physician provider in one year! The LA Times published an article on the results of the work of the Harvard/Duke teams.


They looked at resource use, salaries, overhead and time involved in each step of the billing process. They interviewed people involved in the billing process. Their work was done for hospitals, but there is one area where the EMS industry may see a comparison – the cost to collect an ER bill. According to the researchers, it took 32 minutes of processing time to collect for a typical ER trip at a cost of $61.54 in billing costs per visit.


Thirty-two minutes sounds like a long time but there are many steps involved in EMS billing.  Automation decreases some time, but many steps involve human review and intervention:

  • Pre-verify insurance
  • If non-emergency, check if contracted or if authorization needed
  • Review trip report documentation for completeness
  • Address signatures if not captured in the field
  • Look at the PCS for completeness and appropriate signatures for non-emergencies
  • Create the claim and assign the correct level of service
  • Select ICD codes that best match the patient’s condition
  • Submit claim electronically (hopefully)
  • Address payment posting
  • Follow-up on secondary payer or patient if needed

This list does not include document requests, correspondence follow-up, or work on denials and appeals. You can easily see where the minutes tick by to work a claim.

The Harvard/Duke team did not consider the costs to educate doctors to document properly (in our case, the cost to train field providers in documentation needs) and they did not look at the effort involved in negotiating with insurers. Their conclusion was that the cost of billing was higher, but certain aspects of the process were more difficult to quantify.

What can an ambulance provider do to be more cost-effective in their billing effort? The collegiate group noted that hospitals benefit from economies of scale that come from having large billing staffs. The size of a billing staff is certainly a consideration. This is an argument for the use of a qualified ambulance billing company who will have the staff, resources, ongoing training and “economies of scale” to help respond to the costs of billing.

However, not every service employs a billing company. You can effectively perform billing in-house and wrestle your costs, but there must be a commitment from management to support the billing effort – on both the operational and billing sides of the house. This means that field providers need routine training updates. Field crews must be held to standards. There needs to be policies and procedures that speak to documentation and compliance (which is, by the way, recommended by the OIG in their Compliance Guidance for Ambulance Suppliers). ePCRs greatly aid the effort to maintain compliance and document well.

Billers need resources – good software and access to support to use the software. Automate where possible. Partner with vendors who can alleviate some of the burden and aid your automation efforts (There are exciting options available from vendors nowadays who can improve the workflow and provide needed information for claims processing or help resolve unpaid claims on the back end.) But at the end of the day, quality people are the answer. There needs to be sufficient staff with access to good software, training and information to do the job well. (Training and information can come from any of these - webinars, conferences, industry publications, software events or state ambulance association-sponsored events).

Management stakeholders must monitor billing reports routinely. Be nimble and prompt in your response to slow pay problems, billing errors or slowdowns and delayed trip reports. Set expectations and share them. Goals can be better met when they are known. Don’t overlook the value of an occasional external audit of billing to ascertain your compliance and billing effectiveness.

Finally, we all know healthcare is fractured and fragmented. I wish my magic wands could solve the problems. We can’t fix it. But we might get a better return at a lower cost with diligence and attention to the details.

Let us know if we can help!

About the author:  Maggie Adams is the president of EMS Financial Services, with 25 years’ experience in the ambulance industry as a business owner and reimbursement and compliance consultant. Known for a practical approach and winning presentation style, Maggie has worked with medical transportation providers and billing companies of all kinds to support their billing, auditing, and documentation training efforts. “Like” EMS Financial on Facebook, follow us on LinkedIn or for more info, contact Maggie directly at or visit