Friday, March 6, 2015

The Changing Regulatory EMS Billing Landscape

The Landscape Has Changed
If you read this space on a regular basis, you know that we frequently discuss the changing regulatory landscape. With Medicare and Medicaid comprising well more than half of all the dollars that flow into many EMS agencies, it’s important that we all understand the way the landscape is changing.

Yesterday the folks at the American Ambulance Association shared their knowledge of major claim review changes taking place.

Today’s blog post is intended to share those changes with you along with some hints on how to properly prepare.

The Medicare “Problem”The Medicare “Problem”
It’s simple. There’s a “problem.”

The Centers for Medicare and Medicaid Services (CMS) estimated that Medicare lost nearly $50 billion to improper payments in fiscal year 2013. That’s roughly one out of every twelve dollars paid improperly!!

If you don’t think there are officials in the Federal Government losing sleep over this, think again. 

The healthcare industry (not just ambulance) is experiencing a big shift in focus and that shift takes on the form of the amount of reviews that we are already seeing across all healthcare provider disciplines. The ambulance part of Medicare payments is a relative drop in the bucket, but when increases in payments is skyrocketing well past expectations, that’s when we all became visible under the reviewers’ microscopes.

“Pay and Chase” versus “Review and Pay”

Any healthcare provider that receives Medicare and Medicaid dollars has always been subject to audit. However, in days past, when an EMS agency was audited it typically meant that there was some pretty large “radar screen” issues that were noted by CMS and/or the Medicare Administrative Contractor or Audit Contractor.

Today audits and reviews take many forms and are more routine in nature.

Due to the alarming number of dollars determined to be paid out incorrectly it appears that CMS now has less and less faith in their own Medicare Administrative Contractors to identify the violators.

CMS is taking back some control over the process as a result.

For as long as we can remember, CMS operated under what we call a “Pay and Chase” system. EMS agencies treat and transport patients, submit a claim for payment, the MAC pays. After paying some statistical geek in a Washington D.C. office produces a graph showing a billing “aberrancy” has occurred as the EMS agency is compared to their peer group.

Out goes the audit letter.

That audit letter typically requested records to be submitted for a sampling of claims already paid. The EMS agency submits those records to the auditor requesting them and claims are then reviewed for appropriateness in support of the claim.

But there’s still too many dollars being paid that shouldn’t be in the eyes of the Feds. So what better way to plug the leak but to review first and issue payment later, versus pay now and ask questions later.

Reviewing then paying is known at a Pre-Pay Audit/Review.

The problem with prepay reviews is that it turns the normal two-week payment floor into a thirty-day or more payment floor, depending on how long it takes for the EMS agency to receive the records request and for the review to happen.

Specific Areas of Focus

CMS has been up-front with us. Their three main target items in 2015 will be…
  • ALS emergency transports- looking at EMS agencies who conduct and bill for a high percentage of ALS versus BLS transports.
  • Dialysis Transports- reviewing EMS agencies who have a large percentage of ESRD-related transports to and from dialysis services.
  • Hospital Discharges- taking a look at EMS agencies that perform a large volume of these types of discharge transports and where that percentage may be significantly higher than the EMS agency’s peer group of other ambulance provider agencies.
What can you do?

Before the request letter for information arrives in your EMS agency’s mailbox, it’s time to prepare right now.

What does that preparation look like?

First and foremost, take a critical look at the supporting “stuff.” Specifically, take a look at your Patient Care Reports and the documentation that goes along with them. Everyone in your agency, from street providers to administration to the billing office, must be detailed and purposeful when looking for shortfalls that may cause an unfavorable decision when audited.

Identify, review, educate and participate. 

If asked to support the claims you are billing, will your documentation back up the medical necessity and reasonableness of the ambulance transport you wish to be paid for? 

Don’t panic. Use your resources and be prepared! Promote an honest dialogue culture to smoke out anything that is broken. Be sure to reinforce documentation and processes that meet the strictest compliance standards. 

Basically, color inside the lines each time, every time and no matter where you exist on the food chain…we all must take ownership of this process. Only then, will your EMS agency attain its compliance goals to remain in the good graces of the people that pay us!

The Ambulance Billing Services blog is brought to you by the staff at Enhanced Management Services, Inc. We are a full-service third-party billing contractor dedicated solely to the EMS industry. Enhanced Management Services, Inc. serves Fire/EMS clients across the United States. To learn more about us, visit our website at
Post a Comment