As I noted in a recent post, 2018 has many numbers that effect EMS operations, documentation and billing. Today’s number is 33. EMS providers may not realize that on average, 33% of all Medicare beneficiaries are now enrolled in commercial Medicare plans (per the Kaiser Family Foundation). Ten years ago, that number was only 19%. According to a panel discussion at the Nashville Health Care Council on January 25th, a leading Wall Street analyst believes this trend will grow as national health plans are gaining more Medicare Advantage members.


What does 33% mean for you? It means that a heck of a lot of patients you transport are in commercial Medicare plans. Whether you are a 9-1-1 emergency provider  or you do non-emergency transports, you need to know differences between fee-for-service Medicare and Medicare Advantage – and how those growing numbers effect documentation, billing and appeals.




Emergency coverage under Medicare Advantage is somewhat different than traditional Medicare. Emergencies follow the prudent layperson view of an emergency. The commercial Medicare plan is “financially responsible for ambulance services, including ambulance services dispatched through 911 or its local equivalent, when either an emergency situation exists as defined in section 20.2 below or other means of transportation would endanger the beneficiary’s health.” There is no requirement for a prior authorization in an emergency. Emergency providers do not need to be contracted or in network with the insurer for reimbursement to occur.


Non-emergencies are different. It’s helpful if dispatch (or a transport coordinator) can ascertain who the correct payer is – this information helps determine what forms may be needed, if a prior authorization is required, or, if the provider is the right company to do the job (you may not be contracted or in-network to do the service). It’s essential that call takers (or coordinators) have access to information about the payer.


Unless required by the payer or by contract, the Physician Certification Statement is not usually required. However, I strongly recommend that providers continue to obtain a PCS form and appropriate signatures for every non-emergency transport. First, it may be difficult to differentiate a fee-for-service patient from a Medicare Advantage patient. It is best to have all necessary forms in hand. Second, it is not a smooth process to have crewmembers try to decide what transport does or does not need a PCS. Instruct crews to obtain the PCS form for every non-emergency transport.


As to medical necessity, if Medicare would have covered the service (as noted in the national coverage determination or a local coverage determination), Medicare advantage will cover the service. (See Section 10.16, Medical Necessity of the Medicare Advantage Manual, Beneficiary & Benefits).




But coverage of the service does not mean that they will pay any provider who rendered the service. This is managed care. The protection is for emergency services. Non-emergency services are rendered through contract or network participation.  If you’ve never contracted before, it may be time to reconsider that position. The following states have higher than the 33% average number of Medicare beneficiaries enrolled in Medicare Advantage plans:


California – 40%                                Florida – 42%                     Pennsylvania – 41%

New York – 38%                                Arizona – 39%                    Nevada – 35%

Minnesota – 56%                              Ohio – 35%                         Wisconsin – 39%

Tennessee – 35%                             Alabama – 36%                  Georgia – 34%


As far as billing, providers may not pursue any more than the plan’s cost-sharing amount as noted in the Medicare Advantage Manual, Chapter 4:


“170 – Balance Billing (Rev. 121, Issued: 04-22-16, Effective: 04-22-16, Implementation: 04-22-16) The guidance in this section applies to HMOs (Health Maintenance Organizations), HMOPOS (HMO Point of Service), PPOs (Preferred Provider Organizations), and RPPOs (Regional PPOs).


 When enrollees obtain plan-covered services in an HMO, PPO, or RPPO, they may not be charged or held liable for more than plan-allowed cost-sharing. Providers who are permitted to ‘balance bill’ must obtain the amount in excess of the enrollee’s cost sharing (the balance) for services, directly from the MAO and not from the enrollee.”


If you did a non-emergency trip without a contract, you are not likely to get paid. If you are an emergency provider and the service was denied, the Medicare Advantage appeals process requires you to agree not to pursue the patient – even if the appeal is not successful. Do you see why you might consider contracting if you provide service in an area with a heavy presence of Medicare managed care? It might be the best route to payment (contracting is a management decision you will have to carefully review.)




The appeals process for Medicare Advantage differs from fee-for-service Medicare. Here is an appeals flow chart process for Medicare Advantage appeals including the timeline for expedited pre-service appeals.


Non-contracted providers must use the waiver of liability form (usually emergency providers, but non-emergency providers can fall into this category as well) as noted in the manual outlined below. What is very important to know is that you cannot appeal without the waiver and by submitting the waiver, you agree not to bill the patient regardless of the outcome of the appeal.


“60.1.1 - Non-contract Provider Appeals (Rev. 105, Issued: 04-20-12, Effective: 04-20-12, Implementation: 04-20-12)


A non-contract provider, on his or her own behalf, is permitted to file a standard appeal for a denied claim only if the non-contract provider completes a waiver of liability statement, which provides that the non-contract provider will not bill the enrollee regardless of the outcome of the appeal. See Appendix 7.”


Appendix 7 - Waiver of Liability Statement (Rev. 105, Issued: 04-20-12, Effective Date: 04-20-1; Implementation Date: 04-20-12)


The growth in commercial Medicare may be a game-changer for you. Make sure you know how these payers are now impacting your service area.


Since the numbers of EMS are motivators of what we do, in coming articles, I will continue to address the numbers driving the topics of concern to every provider and billing agency. We will bring you practical advice or action steps you can take to better cope with the “numbers.”


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 support their billing, auditing, and documentation training efforts. “Like” EMS Financial on Facebook, follow us on LinkedIn or for more info, contact Maggie directly at or visit