The election is over and a new day has dawned. We know there will be changes to healthcare, but we don’t know exactly what those changes will entail. However, there are steps that everyone in the ambulance industry should take to prepare for whatever the new year brings. Regardless of what happens, ambulances will continue to respond to emergencies and perform routine transports… and they need to be paid for service. Let’s talk about what you can do as a dispatcher, field provider, biller and manager.

Dispatch

There are still many who are uninsured. It is possible that people on Medicaid may change in the future. The uninsured/under-insured often have healthcare issues that worsen due to lack of care. Suddenly, there is an emergency and 9-1-1 gets the call. Dispatch centers will remain vigilant for these patients. When the call comes, whether emergency or non-emergency dispatch, it’s important to get the best demographic information available at the time of the call. Knowing the correct spelling of the name of the patient, their proper address and date of birth helps create the best medical record of the patient’s encounter with EMS.

For non-emergency call centers, we urge that you try to capture insurance/payer information. This information will be critical to the organization’s need for prior authorization or certificates of medical necessity. Patients will change insurance – now (it’s open enrollment season for insurance) AND in the future. When ambulance companies have the right insurance information from the start, they will know how to best handle the call.

Field Providers

Certainly, for now, the focus will remain on the documentation of medical necessity for transport. This year we’ve seen field providers sent to prison for false documentation, ALS-1 emergencies were targeted for over-billing and just last week a report from Palmetto discussed documentation problems for BLS emergencies and non-emergencies. The requirement for quality medical necessity documentation will continue. Field providers – whether emergency or non-emergency – need to make sure that trip reports clearly show why the patient needs an EMT or paramedic at their side. In other words, it must be crystal clear why the patient can only be transported by ambulance. Yes, there are transports for which there is no medical necessity for the patient to be in an ambulance. If the patient does not need ambulance, that must also be clear. This information is essential to determine who should be billed for the trip – Medicare or Medicaid, the patient or possibly the facility.

Concern about healthcare fraud has existed for many, many years. The Affordable Care Act (“ACA”) had several provisions to combat fraud and abuse. More money was directed to prevent and fight fraud, auditing grew, background checks were intensified and federal sentencing guidelines were increased. But fraud efforts did not start with the ACA; the Deficit Reduction Act of 2005 discussed federal False Claims Act. State laws have tightened in regards to dealing with fraud, waste, and abuse and whistleblower protections for reporting those issues. It is to be expected that scrutiny of medical documentation will continue as we go forward.

Field providers also need to gather insurance information whenever possible. There will be changes in insurance coverage. Field providers have access to patients (and sometimes their families) as well as to sending and receiving facilities. Like call centers, we urge field providers to gather as much demographic information as possible about the patient.

Billers

Billing makes the decision as to what payer receives the bill for the claim. Compliance is an essential component of billing, but so is making sure that the bill gets to the payer responsible for payment. The responsible payer may change. For now, tighten the process of pre-verification. This is the time of year that people are making the decision as to what payer will provide coverage. Premiums for some health insurance plans are projected to rise in coming months. There is uncertainty in the wind. Do not rely in the information you have in your system from the last transport. Verify every claim.

The future may have consumers participating more in their healthcare choices. That means there may be different deductible and co-pay amounts required from patients. The patient-pay billing process may change. Therefore, now is a good time to look at how you handle patient billing, follow-up statements and collection agency arrangements.

Management

I think of management in three parts – wrapping up what you have been recently working on, meeting today’s needs and preparing for the future.

·         Wrap-up: In this post-election time, it’s a good idea to intensely view accounts receivable. See where you need to renew efforts to collect or resolve. Run reports on denied claims and why they denied. Look for trends.

·         Today’s needs: Fix the problems that were identified in A/R management and denials. Look at the billing process. How long from date of service to claims creation? Can your process be tightened or improved in any way possible?

·         Prepare for a new landscape: Will there be changes to the amounts of reimbursement? It is possible. That is one reason why the billing process must be streamlined. Management must have assurance that every legitimate dollar available to the organization gets paid to the ambulance service. There may be new billing processes and/or payers. Training will be needed for billing staff. Plan for the training. Stay very closely tuned to state and national ambulance associations. Keep up-to-date with Medicare and Medicaid alerts.

We will learn in the new year what awaits healthcare. Get your house in order now so that you have the time and energy to respond to whatever comes along.

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 maggie@ems-financial.com or visit www.ems-financial.com