Routinely, we are asked questions about the nuts and bolts of billing, documentation and compliance. This week’s questions addressed levels of service (how to document and how to bill), facility payment delay tactics, and the obligation to pursue patient balances.


It’s a good idea to occasionally revisit the basics. We get busy and sometimes forget the foundations of what we do and why we do it. Today we are reminding you of three places you can go to get some of the basic building blocks for ambulance compliance.


How to Document & How to Bill


This week we were asked to explain a specialty care transport. The organization had not billed for a specialty care transport for quite some time and they were providing the service with assistance from the nursing staff at the local hospital. The provider needed to know the best approach. Let's start with the definitions for levels of service. Go here to see the definitions, including specialty care which is outlined on the second page. These definitions first appeared in the Federal Register in February 2002. They are also mentioned in the Ambulance Benefits Policy Manual Chapter 10, Section 30.1, Definition of Ambulance Services (Rev. 226, Issued: 9/12/16), click here.


Specialty Care Transport (SCT) Definition: SCT is the interfacility transportation (as defined below) of a critically injured or ill beneficiary by a ground ambulance vehicle, including the provision of medically necessary supplies and services, at a level of service beyond the scope of the EMT-Paramedic. SCT is necessary when a beneficiary’s condition requires ongoing care that must be furnished by one or more health professionals in an appropriate specialty area, for example, emergency or critical care nursing, emergency medicine, respiratory care, cardiovascular care, or an EMT-Paramedic with additional training…. (I’ve added the underscoring for emphasis)….To be clear, if EMT-Paramedics - without specialty care certification or qualification - are permitted to furnish a given service in a state, then that service does not qualify for SCT. The phrase “EMT-Paramedic with additional training” recognizes that a state may permit a person who is not only certified as an EMT-Paramedic, but who also has successfully completed additional education as determined by the state in furnishing higher level medical services required by critically ill or injured patients, to furnish a level of service that otherwise would require a health professional in an appropriate specialty care area (for example, a nurse) to provide. “Additional training” means the specific additional training that a state requires a paramedic to complete in order to qualify to furnish specialty care to a critically ill or injured patient during an SCT.


If you are working with another organization and you are sharing resources (like the use of specific staff), it’s a good idea to look at what the manual says about joint responses. Medicare does not say what amount of money the two providers should share, but it does discuss the importance of joint response arrangements (see section 10.5 of the manual).


Nursing Home Payment Delay Tactics


Another question that we were asked this week is how to handle the nursing home’s request/demand for a denial from Medicare before they pay the bill. This request is either a misunderstanding of the rules or a delay tactic. You do not need a denial for a service where the regulations require the nursing home to pay under the patient’s Part A coverage.  How do you prove to the nursing home what they are supposed to pay? Again, go to one of the basic building blocks of billing – the Medicare Claims Processing Manual for Ambulance, Chapter 15, click here. Section 30.2.2 outlines all the services for which the nursing home is responsible to pay. The best way to work with the nursing home is to show them what the manual says and to ask them to show you what regulations they follow. Usually, a look at the rules will resolve any confusion on the part of the nursing home.


Reasonable Collection Effort


There are a lot of changes about to come to healthcare payments but for right now, providers have a responsibility to collect co-payments and deductibles. These are the rules by which we live. A reasonable collection effort means that you put the same effort into collecting from private patients as you do Medicare beneficiaries whose co-pays and deductibles are supposed to be pursued. The Medicare Provider Reimbursement Manual, Part 1, Chapter 3, Section 310 says:


310. REASONABLE COLLECTION EFFORT To be considered a reasonable collection effort, a provider's effort to collect Medicare deductible and coinsurance amounts must be similar to the effort the provider puts forth to collect comparable amounts from non-Medicare patients. It must involve the issuance of a bill on or shortly after discharge or death of the beneficiary to the party responsible for the patient's personal financial obligations. It also includes other actions such as subsequent billings, collection letters and telephone calls or personal contacts with this party which constitute a genuine, rather than a token, collection effort. The provider's collection effort may include using or threatening to use court action to obtain payment. (See §312 for indigent or medically indigent patients).


Obviously, some patients cannot afford to pay. I recommend you establish a financial hardship policy and use the Federal Poverty Guidelines as your standard. These are published every year in January (not yet this year).


If you check the references we’ve outlined herein, you will find some of the basic building blocks for billing compliance.  Let us know if we can help!


About the author:  Maggie Adams is the president of EMS Financial Services, with over 20 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. Check out our newest documentation training webinars and billing webinars on our website.Friend EMS Financial on Facebook, or for more info, contact Maggie directly at or visit