Probably the most-requested session I will present during the upcoming fall conference season is “Why Don’t Providers Get Paid?” There are several reasons EMS does not get paid for services. Since I will be seeing so many of you in the coming weeks (can’t wait!), I will hold off on giving advice on several of these topics. However, there is one problem that seems to be getting worse - I am really surprised by this – the problem we see growing significantly is billing errors.

I believe we understand the root cause of some of these problems, but I will come back to that topic further down in this piece. Let’s talk about the problems we are seeing and what you can do to address them so that you obtain better, more reliable reimbursement:

·         Origin and destination modifiers that are not correct – we see emergency transports where the destination is “S” for scene, “R” for residence and “N” for skilled nursing facility. Emergency transports go to the hospital.  We have also seen an increase in claims being coded as “H” for hospital when the patient actually went to the “P” physician’s office. A hospital is a covered destination; a physician’s office is not. Putting “H” on the claim makes it appear to be a covered service and could lead to an overpayment. Using incorrect modifiers leads to denials from all payers.

·         Hospital to hospital trips billed as emergency or billed as Specialty Care Transport (SCT). Can a hospital to hospital trip be an emergency? Of course, it can! BUT, make sure there actually WAS an emergency involved. Otherwise the transport is likely non-emergency. As to Specialty Care Transports, this is the one where we see lots and lots of confusion. Just because a nurse was on board the ambulance does not automatically make it an SCT transport. The manner in which an ambulance is staffed is not the definition for levels of service. For SCT, it had to be a facility to facility transport of a critically ill or injured patient who needs a level of service beyond the scope of a paramedic. Don’t know what the “scope of a paramedic” is? Easy! Go to your state department of EMS (usually listed under the Department of Health). There will be a list for scope of practice for all levels of providers and there will be information on what drugs paramedics can administer in your state.

·         Bill the correct payer – whether that payer should be the facility under the patient’s Part A benefits, that payer should be hospice instead of straight Medicare, or the claim should go to a commercial Medicare plan and not Medicare, you want the claim to go to the right payer from the get-go. Verify, verify, verify!

·         Clearinghouse hold-ups – review the clearinghouse reports in a timely manner. Make sure that the claims made it to the clearinghouse doorway and then assure they got out the doorway to the payer. Clearinghouse are happy to demonstrate their reporting capabilities. Check with them and get an update on how they can help you.

·         Under-billing ALS-1 Emergency and ALS 2 – what a bummer! Less reimbursement because the claim was under-billed. Review the definitions again. If your documentation supports billing at a certain level, go for it (notice I said “if the documentation supports billing”).

·         Too many denial requests – check to see if denial requests are growing (we hear this complaint often). If the documentation does not support billing, or medical necessity is not met, the appropriate step is to bill the patient or seek a denial. Yet, there may be a documentation problem. If that’s the case, talk to management and operations and hopefully the crews will get updated training with subsequent accountability for their documentation. However, if the problem is billing fear, it may appear that more requests for denial are going out than requests for reimbursement. Again, if documentation supports billing, bill.

So what is the origin of billing problems? We see a couple common problems. Under-staffed billing departments is an issue. We also see staff that does the same thing they’ve always done because that’s what they’ve always done (which leads to under-staffing because volume grew). Look at your process – can it be streamlined? Are the reports you generate actually being reviewed? Does your billing process make common sense?

Management, please! Look at your billing department – is there good lighting? Is the workspace the best it can be? Last but not least, do ALL your people have access to ongoing education? Start with your billing software vendor to see what they can do to help you. Attend online events like Medicare and Medicaid webinars and other available options. Provide access to as much information as possible.

If the billing operation is staffed appropriately, the workplace is well-lit and reasonably comfortable and the billers have the information they need, mistakes lessen and reimbursement improves. What a wonderful thing!

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