Friday, January 13, 2017

To Bill or Not to Bill?

Shakespearian EMS?

We can only wonder what the documentation would look like if the great bard Shakespeare would have been a member of the EMS community.

To Bill or Not to Bill?
“Dispatheth via troubadour to yonder hamlet for a person swooning with the vapors.”

Okay…enough of that. But we borrow a take on the famous To Be or Not to Be and tweak it to ask an important question.

To bill or not to bill?

From Conversation

In conversation with a client recently, we had the opportunity to discuss how we, here at the billing office, review each Patient Care Report (PCR) carefully and then make a decision how to bill the resulting claim.

For some persons in the room that day, a concern arose about what would happen if no billing occurred. Then one of the persons who were part of the conversation said this…

“Look, it’s not whether we bill it or not, period. It’s whether we bill to insurance or not.”


That one statement changed the tone of the entire conversation.

Every billing office must read the documentation contained in the PCR and determine if the billing will go to the patient or will the billing be able to be billed to the patient’s insurance.

If the patient has Medicare or Medicaid, of course there are certain hoops that we may have to jump through in order to make that happen- if we are going to bill the patient or not. But, if the PCR we are presented with does not make a clear case that the patient met the medical necessity test and/or the trip just wasn’t reasonable, then this billing office is certainly not going to bill the insurance payer- especially Medicare and Medicaid.

However, we will still bill to the patient and again that is assuming that we can do so statutorily.

It’s all in the detail

What we advise every EMS provider who authors PCRs to do is to use the greatest detail you can when describing your ambulance treatment/transport scenario.

Remember you are ultimately answering the big question…

Is transportation for the patient at this moment by any other means contraindicated for this patient?

Only you, as the EMS provider describing the incident, can provide the information in sufficient detail to prove without a doubt that the patient you transported and now look for insurance to be billed could only be transported by ambulance. You are explaining, if the patient were to be transported by any other means it would potentially be detrimental to the health and overall well-being of the patient.

Or, you may be providing detail in your PCR that points to the opposite.

Your patient called you, in essence, for convenience for any number of reasons- he/she has no transportation available to reach healthcare options, he/she elevated a non-emergent condition to an emergent condition, he/she feels entitled to your services.

Whatever the reason you must document truthfully regarding your patient’s overall condition using clear and precise clinical documentation that contains enough detail and specificity for your billing office to decide if the patient’s insurance can be billed within the boundaries of the rules and regulations that exist.

Billing Office Frustration

What is most frustrating for an EMS billing office is when the biller can read a PCR and visualize that there is more going on than what has been presented.

Your EMS billing office cannot read between the lines. You have to provide the lines…all of the lines…of detail in the explanation of the scenario in the PCR to erase doubt about the medical necessity of your patient and the reasonableness of the trip in order for the billing office to create a claim and submit to insurance.

It’s so hard to read a PCR on our side and understand that the patient truly needed your services only to be lacking adequate clinical documentation to support the billing action. And so, the billing office then must either delay billing the claim to seek clarification or ultimately bill to the patient and not insurance because the documentation does not support billing to the payer source.

This is both frustrating to the patient and the billing office staff together. We look to you as the EMS provider to do your best to curb the frustration which is right for you as a professional, the billing office and the EMS agency you represent.

The Ambulance Billing Services blog is brought to you as an educational tool by Enhanced Management Services, Inc. Enhanced Management Services, Inc. is an all-EMS third-party billing contractor serving Fire/EMS agencies across the United States. To learn more about who we are and what we do, please visit our website at and click on the “Get Started” button on any landing page.

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