Several trends in the industry appear to indicate the days of consistent growth in revenue are quickly vanishing. As a result, EMS agencies are being confronted with a troubling revenue decline. To make matters worse, agencies are facing continual pressure to increase revenue in an attempt to offset the costs of delivering EMS services.
Formally considered an economic lifeline for EMS agencies, reimbursement for non-emergency transports is now increasingly difficult to obtain. The Medicare Payment Advisory Commission’s report to Congress in 2013 led the industry shift, focusing on a need for increased attention on emergency and non-emergency claims, including an increased focus on the relationships between providers and facilities. Types of ambulance transports that came under the microscope included dialysis, repetitive, hospital to hospital, hospital discharge and non-emergency transports originating in a skilled nursing facility.
Responding to Increased Scrutiny Over Non-Emergency Transports
Poor documentation, like with emergency transports, are the leading cause of denials even for non-emergency transports. Auditors and payers reviewing non-emergency PCRs have typically cited documentation issues directly related to the mental and physical condition of the patient, such as:
- Bed confined patients with no documentation supporting the bed confined status.
- Patients documented as morbidly obese with no supporting documentation such as the patient’s weight and height.
- Alzheimer’s or dementia patients that are acting normal during transport.
- Patient documented as not able to sit for the time required for a transport, who upon arrival are sitting or are being transported less than 10 minutes away.
- Incomplete physical mobility and secondary assessment information being documented in the PCR.
PCS (Physician Certification Statement) forms are also included in documentation issues noted by payers and auditors. Findings such as incomplete or improperly completed PCS forms, PCS documentation that conflicts with PCR documentation and no reason why the patient is being transported to another facility can delay or cost an agency valuable revenue.
This being the case, EMS agencies have needed to take a hard look at the process their facility uses to determine which transports to take and how to document them accurately.
Developing Effective Call Intake and Dispatch
EMS agencies should perform a data analysis of their denial rates for non-emergency transport claims separate from the denial rates for emergencies. Once this data is obtained, a clear plan can be put in place to address these transport requests. Communicating this plan to all appropriate parties, including the requesting facility, call intake staff and dispatch staff, is necessary to make meaningful change.
An effective call intake and dispatch can help save your agency money by:
- Eliminating transport requests that will not be paid by Medicare or other commercial insurance payers – by verifying eligibility and medical necessity for each transport prior to it occurring.
- Collecting a PCS and other necessary or helpful forms prior to the transport being initiated to ensure accuracy and completeness.
- Pre-authorizing transports for insurance companies that require such, thereby ensuring your agency is likely to be paid for the transport.
- Providing crews with all the necessary information required for the transport at the time of dispatch, thereby cutting down on utilization times.
Pre-screening Repetitive Type Transports
Agencies should also consider pre-screening patients who require repetitive transports, sending a qualified staff member such as a paramedic or EMT to the patient’s residence prior to agreeing to transport the patient to their weekly dialysis appointment or other type appointments to determine medical necessity. Perform a detailed exam to assess the patient’s current physical and mental status, and document the findings including the use of pictures of the patient, if permissible, for future pre-authorizations. Repeat the exam every 45-60 days to ensure an accurate assessment is on file that agency crews can access and document accordingly.
Understanding the Medicare Pre-Authorization Process
Implemented in 2014 in response to the Medicare Payment Advisory Commission’s report, Medicare followed state Medicaid programs and commercial payers by looking for pre-authorization for non-emergency transports. Effective now in pilot programs, New Jersey, Pennsylvania, South Carolina, North Carolina, Virginia, West Virginia, Delaware, Maryland and the District of Columbia require pre-authorization. This pilot responds to Medicare’s requirement of pre-authorization for all repetitive, non-emergency transports billed. This includes extensive documentation requirements that, despite Medicare’s best efforts, have created a headache for agencies in the aforementioned states.
However, when CMS evaluated the effectiveness of the program, Novitas experienced a 71% decrease in expenditures once implemented—over $13 million in savings each month. However as a result, numerous ambulance companies went out of business.
To avoid any non-payments, EMS agencies should look ahead to implementing documentation procedures that meet the more rigorous standards. The Medicare Pre-Authorization Process is expected to rollout nationwide in 2018 or 2019, and being prepared with such procedures could mean the difference between payment and nonpayment.
In just the last few years, ambulance providers have faced an increase in the number of reviews and audits being conducted by CMS and commercial payers. Therefore, it is important to conduct a thorough review of your agency’s processing of non-emergency transports. For more in-depth information, click the link to view an hour-long webinar on “Five Non-Emergency Ambulance Transport Recommendations for Optimal Reimbursement.”