Geez, but the ambulance industry has gotten to be a tough place for some to work! Recent articles talk about providers pulling out of a state because of low reimbursement rates and another article discussed how Philadelphia providers can’t make any money. The really scary stuff is the 37-year old EMT who was sent to prison for over three years for how his organization tried to make money (not the right way). Last but not least, there is the $3.6 billion in healthcare civil fraud recoveries captured by the government in fiscal year 2015, a fact that can put grey in your hair.

Yes, it IS harder to make money which means ambulance providers of all kinds need to focus on doing things right and not just from the compliance perspective. Obviously, compliance is an ever-present requirement, but your process is important too. Today we advocate auditing your process. We talk about the process problems we see in many ambulance organizations that impact providers’ ability to make money. We offer tips to improve your process – lack of authorizations, emergency trips missing critical info, inconsistent verification of information and facility problems. While you can’t change the reimbursement rates for your service, you can take steps to assure that you get more of what is available and what you are due to be paid.

Audit the Process

Audit is not only a function of compliance. Many people think of auditing as something you do to your claims to assure that documentation and claims preparation were done properly and in compliance with Medicare’s requirements. Yes, this is a mighty important thing to do, but there is much more to auditing than what you are now doing.

Auditing helps diagnosis and troubleshoot problems. Say you have a problem with outstanding PCS forms. Start tracking the issue. Divide your total non-emergency trips by the total PCS forms received timely to see percentage of forms compliance. Look to see which facilities did a good job. Armed with information, you can do an educational outreach effort to targeted facilities and physicians. Any time there is a process or a connection between departments or between processes, you can look at it and quantify what’s going to analyze the issues to get to a solution.

Use your software to help you audit using the reports you run. Whether it’s ePCR software, dispatch software, billing software or an integrated solution, they all offer reports that will help you pinpoint trends. But also look at the people doing the work and see how they work. Below are examples.


Get the authorization you need – it’s called “prior” authorization for a reason. For most of you that means it needs to be obtained in advance of service; certainly, in advance of billing. We see countless providers get behind in billing or altogether miss the chance to bill because they do not have an authorization. Providers believe that they have time to get the auth, so they don’t always apply the resources necessary to get it done timely. If possible, put more people to the task. If billing is behind due to an authorization problem, go audit the authorization process. Look at who performs transactions, how they do it, how many each person does and compare results. See what’s working and what’s not working.

Emergency Trip Problems

There are three things we see missing from emergency trips and each of them will hold up a trip from billing – signatures and no info about dispatch and assessments. In the case of signatures, it is possible you may never get paid (without a signature the bill may get sent to the patient which may lead to no payment). Monitor which crewmembers are slipping with signature compliance. If there is a problem with signatures, do focused training with the crews. Remind them that there are options if the patient is incapable of signing (as is often the case in an emergency).

Proper documentation of how and what you were dispatched for coupled with documentation of an ALS assessment may support billing at the ALS-1 Emergency level. One thing is for sure – no documentation of these topics can have an impact on your ability to obtain legitimate reimbursement. To help spot this issue, run a report of BLS emergency trips. Pull a sample. Is it possible that any of the trips you reviewed could have been ALS-1 emergencies (but lacked the documentation)?

Inconsistent Verification

Verification goes on during the pre-billing process. If your billing staff complains that they have to re-do the verification of the claim that means claims are delayed. Again, audit is the answer. Go look at the transactions being performed in pre-billing. Are they thorough and complete? Are they getting the information right the first time? If the process has to be touched again later, it creates a delay. Delays in processing lead to cash flow problems.


Here’s a dilly of a problem facing EMS providers – how and when to bill facilities for transport. The challenges are two-fold; first, we have to follow the regulations and second, we have to get paid. Oh, did I mention that they happen to be customers and providers are dependent on their business?

Let’s start with billing skilled nursing facilities (SNF). If the patient is a Medicare beneficiary, the SNF is responsible for certain transports while the patient is within their first 100 days in the SNF. This is important: the SNF is responsible for certain transports, not all transports, certain transports. They receive money as part of their payment system to cover those transports. The facility may challenge the provider. They tell the provider that a denial is needed to prove that they must pay. This is not the case.

Next, monitor your accounts receivable aging closely in regards to facilities. Do not let the facility get behind on paying you. If they want individual bills for each trip, do it. If they prefer a statement monthly with all trips performed, oblige them. Get the bill to them in the format they need. This is part of your customer service to the facility. But once you do bill, stay consistent and very, very diligent about follow-up. It is rare that I go into an ambulance company today that does not have lots of dollars tied up in facility bills. Email them, call them, visit them, whatever it takes, but make sure you are getting your money timely. You will be protecting yourself and you will be doing them a service as well; timely payment helps compliance for both you and the facility, as well as protecting your cash flow.

Let us know if we can ever 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