Almost every billing office I enter has the same complaint, “field crews don’t give us enough documentation!”  When I do documentation training, EMTs and paramedics say it feels to them that everything is about billing. I taught a class recently where crew-members told me they worry that billing will “release the flying monkeys on us!” It’s an “us and them” kind of world. Indeed, there can be tension. Let’s talk about this problem and offer some potential solutions.

First and foremost, let’s try to appreciate the other guy’s position. EMS is hard work. Period. Emergency providers can stand your hair on end with stories of what they encounter. Yet the non-emergency world has its challenges as well – working with the elderly whose bodies and/or minds are disintegrating while navigating the trials of hospital and facility operations. Field providers are always up against a ticking clock. The billing world has its own problems.

Billers complain that Operations is not responsive. Billing staff worry about the patient too. They don’t want those sick, elderly patients to get bills that someone else is supposed to pay. To save the patients, they need information. However, having the info is not a guarantee that an insurer or Medicare will pay. So billers wrestle with payers (calls, emails, faxes only to repeat the cycle all over again). Billers often hear that they need to be more productive, get more bills out the door, get more claims processed, and make more calls. The organization is always worried about money. Without money, the ambulances can’t run and be there for the next patient. These are the battle-cries that billers hear.  In addition, there is the constant worry about being audited by federal or state officials. The clock is always ticking for the billing department too.

Both groups – billing AND the field – work under pressure, different kinds of pressure, but stressful nonetheless. So what can be done to make it better?

Billers & Billing Companies

·         There may not be a documentation problem; there may be a reading problem. Billers tend to focus on the narrative section of the patient care report. Teach billers to review the entire trip report.  Information about the performance of an ALS assessment or the patient’s advanced Alzheimer’s may be located some place other than the narrative. It’s a bonus when you find payer information squirreled away in the report!

·         Have billing and operations get together occasionally. A simple meeting can be very helpful to improve work flow. It helps both sides understand the other’s issues and work toward a resolution for all concerned. (If there is a lot of tension, consider setting ground rules so that it is a “meeting” not a gripe session.) Perhaps billing had no knowledge of the problems the field encounters with a specific facility. A conversation explains why getting the Physician Certification Statement properly completed for patients from that particular facility is such an ongoing issue.  Or maybe Operations did not know how important it was for emergency billing to have access to dispatch information.

·         Has anyone in billing been on a ride-along? A ride-along may not be appropriate for your service, but where possible, it can go a long way to help someone from billing really understand what crews face in their daily work. Ditto on having someone from billing sit in the call center – just listening to how requests for service arrive is an eye-opening experience for billing personnel.

·         Do you have an addendum policy? Do billers know when it is appropriate to seek additional information from field providers? We see trips routinely sent back to Operations for issues that the biller could address. For example, if there is no beneficiary signature, consider billing the patient and sending the patient a billing authorization form. If the PCS was not obtained for a non-repetitive patient, use the 21-day rule outlined by CMS. Sending signature and PCS requests back to Operations can clog the pipeline and lead to unbilled claims. Have good policies on when to seek additional information from the field.

Field Crews

·         Tell field providers that you need better documentation so that you can bill and watch their eyes roll and the wind go out of their sails – the organization’s need for money is generally not a motivator. EMTs and paramedics did not get into this business because of the money. Teach crews WHY they document and how their documentation is related to the patient – to create a good patient record, to be able to communicate to others about the patient and their condition, to QA our care so that we learn to improve and to enable statistical tracking of what we do by counties and states (response times, types of calls, etc.).

·         Crews do not need to write more; they need to write the right things. Objectively note why the patient needs an EMT or paramedic at their side. What is it about the patient’s condition that indicates they need an ambulance (and not a wheelchair van)?

·         Have a time deadline by which documentation needs to be complete.

·         Consider cycling members of the field crew through the billing office for a day. They can answer questions, explain trip report documentation and, most importantly, come to a fine appreciation of the obstacles faced by billing.

·         Teach crews how you want them to talk to patients about money. Patients express fear or concern about the ambulance bill.  Occasionally, the patient may want to refuse transport because of worry about cost. Crews need a consistent response to patient’s concerns on this topic. A good answer to the patient’s question about money or billing will go a long way to avoiding or solving future billing problems.

Last but not least, communication, communication, communication!! Keep crews and billing personnel up-to-date on the latest issues, provide ongoing education opportunities and assure that everyone knows what goes on in the company – via newsletters, emails and ongoing real-life meetings. Taking these steps will go a long way to help. Remember, you are all on the same team – TEAM PATIENT!

Let me know if there is anything we can do for you.

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