Last week, I posted a news story about an ambulance company that struggled because so many of their patients received payment directly from the insurance company but neglected to forward those payments to the provider. This is not uncommon. When I shared the piece online, we got a flurry of response. I promised to write an article with tips providers could use to address this most frustrating problem.

The most aggravating aspect of this situation is that it happens most often to emergency providers. There is another important fact - a large portion of emergency providers are non-profit. When a call comes to 911, they are mandated to respond. Consequently, they often hold the bag - they must render the service and then don't get reimbursed because some patients pocket the payment received from insurance. Emergency providers need to be paid so they can continue to serve their communities.

To billers and providers, it can feel as if the patient gleefully awaits that payment, so they can quickly go splurge on some personal desire. Yes, there are patients who do know how to game the system. But for many patients, the problem may be that they are not aware that their insurer will pay them directly. The patient does not know to be on the lookout for the check. Try taking these steps:

  • Bill the insurer.
  • As soon as the insurer is billed, “flip” the claim in your software system to patient pay. Send the bill to the patient. Include a statement that the insurer was billed, and the patient is responsible to forward the payment (as well as any co-payments and deductibles).
  • Remember, many people do not open their mail – especially recovering patients. Attempt to call the patient to alert them the payment may come to them.
  • Put the account in a work queue to be closely monitored. If you see the payer processed the payment, alert the patient again.

 

Assure there is a policy that outlines the organization’s approach to patient accounts when the patient does not surrender the check to the provider. This can be handled differently than other routine patient accounts. If the provider has information that the patient received reimbursement, we recommend waiting a reasonable amount of time to receive that payment. If payment is not received, the account should promptly go to collection. Another option when payment is not received from patients who received reimbursement is to take the account to the local district magistrate. Again, any action taken with collection or filing with the magistrate should be done based on the written policy of the organization. It is important to maintain consistency.

What about those signatures that the paramedic captured in the field? The signature form was carefully worded and said the patient “assigned their benefits” to the provider. Yet still patients receive the check. EMTs and paramedics have been trained and now do a good job of obtaining an assignment of benefits. But some payers, particularly the Blues, do not follow the standard. State ambulance associations and provider groups have fought this for years. The payers offer contract, which often comes with rates that are unacceptable to emergency providers and the cycle of patients receiving payment continues.

I hear the battle cry, “but it’s insurance fraud!” I’m not an attorney, but I can tell you how this usually plays out. The patient has insurance that says it will cover an emergency. The insurer covers the emergency. The method by which they cover the emergency is to reimburse the patient directly. The insurer does not have to pay the provider directly (unless required by state law). Therein lies the rub – the insurer will not pay directly unless the provider has a contract. Contracts are not always attractive to emergency-only providers as the rates can be daunting.

On the topic of contracting – it is a personal decision for each emergency ambulance service. Here is some information to help in that decision-making process. Insurance is a regional phenomenon which means there are usually three or four main insurers that provide coverage in a geographic area (aside from Medicare and Medicaid). If your service is in an area with high numbers of members who receive their insurance from a payer who routinely sends checks to patients, you may have to consider if contracting is best for your service.

How do you make that determination? Look at your billing reports and see what is happening. How many claims are billed to the “patient-paying insurer?” Then look to see who many of those accounts get paid. If your population does a good job of forwarding payment to you, contracting may not be needed. On the other hand, if your population does not remit payment and your billing department spends a great deal of time and effort pursuing those accounts with little reward, then contracting may be a better option. The internal numbers need to be reviewed. There also needs to be a review of what the insurer is currently willing to pay (unfortunately, there are little to no negotiation option here). If it looks like contracting could lead to an improvement in cash flow, it may be time to pursue that path.

I’m sorry to say that patient payment from insurers has been a problem for many years. I urge providers and billers to be as proactive as possible to get your justified reimbursement. Finally, keep firing up your legislators so they remain informed about this difficult burden.

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