This situation makes me sad for everyone involved – ambulance companies working with these patients, billing departments trying to figure out how the heck to get paid for these transports, but mostly, my heart is heavy for the patients themselves. Unfortunately, the worlds of both emergency and non-emergency providers are feeling the pressure from increasing mental/behavioral health patients and their needs. Let’s quickly talk about the issues and then let’s provide some guidance from the billing and documentation perspectives to help you better cope with the problems you face.

Recent national reports have noted that in the past year, the number of mental/behavioral health facility options has decreased. To make matters worse, the number of outpatient treatment options has dwindled. Consequently, more patients are landing in the emergency room. These patients are a combination of drug problems (you are all too familiar with the growth of opioid abuse) and other mental/behavioral health conditions. This means that more emergency transports are related to mental or behavioral health incidents.

Many mental health patients need two transports – there’s the initial emergency when the patient is taken to the ER and then there’s the second trip when the patient is taken to a mental health or rehab facility. Here’s the tough part – once you got the patient to the ER, some of them are stuck there for a day or more as they wait for a spot in a facility to meet their needs. The American College of Emergency Physicians held their annual meeting last week. According to a report published on (click here) and another report published by Kaiser, psych patients are waiting far too long for the care they need due to lack of resources to care for them. That’s a serious situation and one I hope gets addressed sooner rather than later.

“A group representing emergency physicians said Monday (October 17th) that hospital emergency departments routinely are clogged with patients who are waiting, sometimes for days, for inpatient psychiatric care.

The American College of Emergency Physicians (ACEP) bolstered its case with data from a poll of more than 1,700 emergency physicians as well as research presented at its annual meeting this week in Las Vegas.”

But there are practical matters for you as providers and billers. Let’s start with the initial emergency call. It’s important to objectively document whatever information is available about the patient’s condition. The patient may have been reported to you as combative, but when you arrive, they are well behaved. Document not only what you see, but what you hear or were told about the patient. This information may come from family, people on the scene or local police. Indeed, the information documented about patients does help in the billing process, but more importantly, the patient care report gives information about the number and depth of these mental/behavioral health problems that may lead to better approaches and solutions. You may note a specific drug use or spot a physical condition being demonstrated by the patient. The physical health of mental/behavioral patients is often exacerbated by their mental health problems. Data we gather tracks the issues, lets us better understand the depth of the problems and help craft better responses.

As far as billing goes, there are two issues – first, billing of the initial transport to the ER which is typically an emergency and billing the second transport, which is usually non-emergency. I caution billers on billing the facility to facility transport – the trip that is taken to get the patient to the psychiatric or rehab care they need.

The trip to the second facility can be a billing challenge. Because it is difficult to find a place for the patient in an appropriate facility, these trips may have what appears to be excess mileage. Look carefully at the documentation – is it noted why the patient is being sent to a facility?  Are there notes about the fact that the receiving facility is the only place that had a bed for the patient? If it’s clear that there is a good reason why the patient is going to a distant facility, the mileage may be very appropriate. If there is a problem understanding the reason for the patient’s transport to a facility, consider going back to the crewmember (in accordance with your company’s trip report addendum policy). If there are ongoing holes in the documentation, consider alerting your manager and/or operational management; more education may be needed for the crews on this important topic.

Be careful billing the inter-facility transport as an emergency. Much of the time these trips are non-emergency; the patient may need care not available at the sending facility, but they have usually been medicated and stabilized prior to transport. There may not be an emergency dispatch for these types of interfacility transfers. And particularly now with psych patients sometimes waiting up to a day and more prior to receiving the necessary care from an appropriate facility, it is less likely that the transport is emergent. Be careful as you look at the whole picture of what occurred with the transport prior to billing.

My deepest hope is that the situation improves for all involved.

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