This piece is about two things – the ambulance industry must be realistic and practical. There is a LOT of scrutiny these days (ALS emergency audits, TPE audits, review of non-emergency transports) and much change on the horizon (non-emergency documentation rules a-coming, a proposed Medicare designed PCS). Realistically, transformation is coming and there are issues of concern. But here’s the second thing we’re going to talk about – the industry must be practical. Patients still need transport, operations must run, billing must be done. Today we address the realistic and practical issues facing the industry and suggest ways to cope.

Realistic Issues and Practical Advice

ALS emergency audits continue – and they’ve spread.

·         Practical advice – ALS emergency oversight grows. If billing done in-house, have an external audit done. If billing outsourced, talk to the billing company and ask when their ambulance billing was last audited. An occasional error with a claim is not a big concern. If there are a significant number of claims with a problem, talk to an attorney. The ALS audit activity is so widespread that legal help is a good idea.

New non-emergency documentation standards were proposed by CMS along with a voluntary Physician Certification Statement (PCS). Note the use of the word “voluntary” for the PCS.

·         Practical advice – loop the marketing team in early on this topic (or whoever routinely visits the facility customers). Facilities will need to be educated if any forms changes are adopted. Also, make sure the call center/call intake group is kept informed. Be prepared to update the education of field providers. Remember that billing staff also needs education on any documentation changes or forms updates. This topic will need a team effort. Start with a meeting of the department leads and keep communication flowing.

TPE audits (Targeted Provider Education) is a new but supposedly routine audit initiative. Providers will receive a request for a routine number of claims. The claims will be assessed. If Medicare believes there is a problem, education will be provided. If the problem does not improve, the stakes escalate.

·         Practical advice - assure staff is on the lookout for any audit request and respond promptly. Next, await the results. If any problem is identified, take steps internally to educate staff and implement corrective measures. Include the identified issue in internal audit efforts. If may take time for Medicare to arrange education. Don’t wait. Take steps internally to keep ahead of any problems.

In July, the OIG released a report stating that Medicare made improper payments of $8.7 million to providers for nonemergency ambulance transports to destinations not covered by Medicare. The issue was transports to diagnostic/therapeutic centers. Consequently, Medicare intends to seek overpayments from providers.

·         Practical advice - diagnostic and therapeutic centers (modifier “D”) are non-covered destinations. But, boy oh boy, is this a confusing topic for billing personnel! Normally, I’d suggest an internal audit to assess the scope of the issue, but that’s going to be difficult to do as a first step. If the claim was not coded with the correct destination modifier, it will be hard to pull a batch of claims to assess the depth of the issue. Take a different approach. Most billing departments have a list of facilities and their addresses in the software system. When those facility names are entered, a modifier designation is assigned. Get a list of facilities and their modifier designation. If any facility was assigned the incorrect modifier, adjust it. Next, run a report on transports to those facilities and check the claims status. This will provide a picture of where there may be problems. Of course, if overpayments are identified, they need to be promptly refunded in accordance with Medicare’s requirements. Finally, education, education, education! Assure all billing staff have a good understanding of this important topic.

Taking these steps can help providers stay ahead of problems. Being proactive allows providers to continue operations instead of being distracted with the reactions and tremendous amount of time needed to respond to Medicare or the OIG if they come knocking.

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 or visit