Let’s look at a crystal ball to see what 2019 has in store for ambulance operations and reimbursement. Better than a crystal ball, I’m going to use my experience this year to talk about emergency billing issues, rural health transports, CMS cost reporting, catastrophe response, Uber & Lyft, widespread audits and patient pay problems.

Emergency Billing

Two challenges I continue to see for emergency billing is medical necessity (usually a BLS-level issue) and ALS-1 Emergency billing. Medical necessity can be confusing for billers. If documentation shows the patient walked, do they need an ambulance? Possibly. It’s important to look at the entire trip report. For example, a psychiatric/behavioral patient may need trained personnel to monitor them and assure their safety. As to ALS-1 emergencies, be careful here! Review the definition of ALS-1 Emergency. Audit activity continues. Look at dispatch protocols. Assure both documentation and billing follow the rules. Perform internal audits and have an external review done on occasion.

Rural Health Transports

Patients in rural areas are often transported to small critical access hospitals (CAH). CAH do not have resources to provide many types of comprehensive services. A hospital to hospital transport in an urban area like my hometown of Philadelphia may be non-emergency in nature. There are several major university medical centers here where patients may be stabilized prior to transport to a facility which has specific services the patient needs. The same approach just may not be possible in a rural CAH. A cardiac or stroke patient may be an emergency as there is so little that can be done when physicians are not available. But the rural provider needs to assure they follow the rules before billing emergency for transports from the CAH. Follow Medicare’s guidance regarding dispatch protocols. Good emergency dispatch protocols will help maintain compliance.

CMS Cost Reporting

Billing departments will be tapped to assist management with CMS’ cost reporting requirements. The best resource available can be found at the American Ambulance Association. The AAA has worked on this issue since it began. They have been in frequent communication with CMS. They have tools and send updated information about what is required. Go to their website and see what they have available.

Catastrophe Response for Billing

2018 brought tragedy on many levels – opioid events, shootings and the ferocious hand of Mother Nature in the form of floods capped by the wildfires in California. No provider knows when a weather event or other kind of disaster or catastrophe might require movement of patients from facilities or in emergency. It’s a good idea for billing personnel to do a quick refresher on the use of the billing modifiers for catastrophe and disaster.

Uber & Lyft Impact on Non-emergency Transports

Increasingly throughout 2018, health systems and payers have contracted with Uber and Lyft to provide low-level non-emergency medical transportation for doctor’s appointments and medical services. This trend is likely to increase. Yet we all know that a car is not always the best mode of transport for the patient – wheelchair van may be better, or, when necessary, an ambulance. There is no better time than now to look at your call intake process. What kind of questions do call takers ask when a facility seeks service? Gone are the days when providers can send whatever the facility requests. Remember, facilities don’t know ambulance regulations; they know the patient needs to be moved. Ask the best questions possible – not more questions, good questions. Try asking, “what does the patient need help with?” The answer to this question will provide the information needed to determine best mode of transport.

Audits – Emergency and Non-emergency

There is a smorgasbord of audits going on – audits of ALS-1 emergency services, the Targeted Probe and Educate (TPE) audits, and the latest announcement that non-emergency services will be audited for transports to non-covered destinations. Audit activity will not go away. Be prepared. To get ready, do an internal audit. Take a sample of the targeted types of transports. Look to see if documentation supports billing as submitted. Address any potential error or overpayment promptly. If unable to perform an internal audit, consider having an external review done. Don’t be caught unaware.

Patient-pay Problems

The lack of cash from patient-pay accounts will continue stymie providers. Deductibles remain high for many patients. Co-payments and cost sharing requirements are also steep. There are now excellent tools available to ascertain the status of a patient’s deductible with the payer. If the deductible has not yet been met, providers can hold submission of the claim until the deductible is satisfied. (Check what your billing software has to offer or investigate Payor Logic or Reimbursement Solutions Group for options).

Under Medicare’s Reasonable Collection Requirements, providers need to be consistent and pursue deductibles and co-payments. Get bills and statements out in a timely manner. Step up your collection efforts through early outsourcing. It’s a competitive world for patient dollars. Every other healthcare provider will chase the patient for payment. Finally, remember the compassion and care given the patient at the time of the call. Take that approach through billing and collection. Have a financial hardship policy for those patients who are unable to pay. Federal poverty guidelines are published the third week of every January in the Federal Register. Watch the January 2019 update for these guidelines and consider incorporating them into your approach to financial hardship.

2018 was a roller-coaster of a year; 2019 is not likely to go smoother. Be prepared and armed with information and the billing process will continue to flow.

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 provide auditing services, assess their billing for best practices and support their billing and documentation training efforts. “Like” EMS Financial on Facebook, follow us on LinkedIn or for more info, contact Maggie directly at maggie@ems-financial.com or visit www.ems-financial.com