On Facebook, I read a story about someone’s experience with the billing department. The storyteller complained about problems with insurance and lamented that things would have gone a lot smoother if only she had not been dealing with “a chick with a bad attitude.” Sigh! If only the storyteller knew just how complicated the biller’s job is and how much goes into the battle with payers. But of course, the storyteller had her own set of worries – a very sick family member and an uncooperative payer.

I’ve worked with many billing departments to both improve their billing process and their compliance. Lately, I see a scary trend – billers are wearing far too many hats. Unlike hospital billing where there appears to be more separation of duties, ambulance billers are often expected to multi-task. The overwhelming fact I see is that it’s gotten awfully hard to do ambulance billing right.

Look, there is no one perfect way to manage billing. What works for one organization will not be successful at another. But it is important to be aware of all that is involved so that the best approach can be applied to the job. Let’s talk about the many tasks of ambulance billing, how they are juggled and what you can do to improve your operation. We want to see you get paid properly….and to be able to keep that money because you did things right.

The Biller as Juggler

There are many balls in the air. Each of these balls contains a list of tasks. Those tasks require various skills and knowledge to manage. Here are options to complete each task:

·         Review trip reports for documentation compliance

o   Train field supervisors or designate someone in operations to QA the trip report for completeness including appropriate description of medical necessity. This means operations will need education on Medicare and Medicaid compliance requirements.

o   When trips are pre-screened by field management, billing becomes the final “check and balance” to assure documentation is correct. This saves time.

·         Verify insurance and get authorizations

o   Consider having the call center get the authorization online at the time the non-emergency transport is scheduled

o   This step assures you are right provider to do the job prior to rendering service (you don’t want to provide non-emergency service for which you won’t get paid)

o   Eases time spent in billing

o   Billing focus becomes verifying completeness of insurance information using online options

·         Follow-up on missing forms and signatures

o   Educate billing staff well on use of Medicare’s 21-day rule for those occasions where the PCS was not obtained for a routine non-emergency trip. We see a tremendous amount of confusion over this topic. The confusion leads to major billing delays, or worse, accounts that need write-off because the PCS was not pursued timely

o   Consider having the call center manage the PCS for repetitive patients. The call center handles the scheduling of these patients and is most familiar with the facilities and physicians involved. A transport coordinator at local facilities could help too.

o   If no beneficiary signature was obtained, ensure billing understands all the options available. We often see billers that forget to check if there is a lifetime signature on file. If none of the signature options are available, teach billing to promptly send a bill and signature form to the patient.

·         Prepare and submit claims (THIS IS AN IMPORTANT COMPLIANCE ISSUE!)

o   Billers must be well-educated and familiar with Medicare and Medicaid regulations plus the rules of regulated payers like Medicare Advantage and Medicaid managed care.

o   Billers also need education about commercial payers

o   Facility billing must be timely and routinely pursued. Facility billing may need to be done outside the normal confines of your billing software. This requires another skillset to manage spreadsheets and invoice tracking.

o   Important note about community paramedicine billing – not all software systems are ready yet to handle billing for these growing programs. Billing staff will need to devise the best way possible to manage CP billing needs.

·         Pursue unpaid/denied claims and patient accounts

o   Every payer has a different system to appeal denials. Billers need to understand the difference in appealing Medicare versus Medicare Advantage. They need to understand the short appeal filing limits for Medicaid and sometimes even shorter for Medicaid managed care. Commercial payers have their own systems.

o   Teach billers the various approaches to appeals and when escalation is appropriate.

o   If possible, assign dedicated people to these important functions.

o   Recognize the skills needed to appeals denials are not the same as the skills needed to pursue and resolve patient accounts. Train call takers in collection tactics and customer service so that phones are managed properly and accounts make it to successful resolution.

The most frequent question I get asked relates to unpaid accounts and goes like this, “why are our accounts receivable large / behind / uncollected / growing?” Interestingly, the question usually relates to cash flow more often than compliance. We cannot overlook that those two things are intertwined – compliance impacts cash flow.

While billers try to keep all these balls in the air, the phone rings, field providers sometimes wander through the office, occasionally they must prepare payroll or manage scheduling and they are the gatekeepers of the organization’s compliance. They need policies on when to appeal a denial and how to do it when the rules differ from payer to payer. They also need to maintain a unique combination of compassion and assertiveness to manage an unpleasant patient call regarding a self-pay account. Gee, no wonder there are times someone may come across “a chick with a bad attitude.” Perhaps we need to rethink how we configure and manage the billing process. I can see why it’s so hard to do ambulance billing right.

It’s tough to get paid. Put policies in place that create a consistent process. Support your people with education. Create checks and balances with internal audit and occasional external review so that problems can be addressed early on. Don’t let your organization get to the point where you are looking at your accounts receivable list and asking, “how did our A/R get like this?”


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. 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