# Medical Necessity Form



## DeepFreeze (Feb 22, 2014)

Okay, so just wanted to clear up a rumor.

I've worked for a couple private ambulance companies here in the Commonwealth of Mass and everyone says things differently.

For Non-emergent Hospital-Hospital, Nursing home discharge, Hospital to facility transfers: A Medical Necessity form is filled out, for Medicare/Insurance so that a claim can be made by the ambulance company deeming that the ambulance was necessary for the transport.

It has a bunch of questions, for those unfamiliar, such as "non-ambulatory patient, etc...basically why can't this person go in a chair-car.

I was told once, when I worked at ye old AMR, that to coach or tell the nurse what to fill out was medicare fraud. I was discussing this with other co-workers, and they never heard this (they never worked at AMR).Has anyone else heard of this?


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## JPINFV (Feb 22, 2014)

Assuming that what gets marked is truthful, why would it be fraud?


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## VFlutter (Feb 22, 2014)

The Nurse or the MD sending the patient should be the one filling out the form based on the patient's medical needs. Ie: Can not tolerate wheelchair transport due to ___, requires Cardiac monitoring/suctioning/etc equipment due to___. It does not makes sense for the EMT/Medic to dictate that paperwork because they are not familiar with that patient and their needs. It would be fraud if they told the nurse to write in things that are not true for them to qualify for reimbursement. Like putting on 2L NC for "comfort" when the room air sats are 98%.


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## DeepFreeze (Feb 22, 2014)

Chase said:


> The Nurse or the MD sending the patient should be the one filling out the form based on the patient's medical needs. Ie: Can not tolerate wheelchair transport due to ___, requires Cardiac monitoring/suctioning/etc equipment due to___. It does not makes sense for the EMT/Medic to dictate that paperwork because they are not familiar with that patient and their needs. It would be fraud if they told the nurse to write in things that are not true for them to qualify for reimbursement. Like putting on 2L NC for "comfort" when the room air sats are 98%.



exactly my point! That is what I was getting at.


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## Akulahawk (Feb 22, 2014)

It's one thing for the crew to clarify the paperwork for the sending facility so that they can fill out the form truthfully, but another thing entirely to coach the sending facility to fill the forms out with false information. 

One way constitutes fraud, the other does not. 

AMR may be telling their people not to do any discussion with facilities/providers to avoid even any _remote_ appearance of fraud. Having some investigators crawling through their billing department over an untrue allegation is just not an experience that they want. So, to avoid that altogether, they make any such discussions verboten and then they can tell any investigators that their crews are under specific orders not to discuss anything regarding medical necessity forms. 

Disclaimer: I haven't worked for AMR, but I suspect this to be the underlying motive behind what they'd do with this issue.


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## medicdan (Feb 22, 2014)

DeepFreeze said:


> Okay, so just wanted to clear up a rumor.
> 
> I've worked for a couple private ambulance companies here in the Commonwealth of Mass and everyone says things differently.
> 
> ...




I've had these questions as well for several years. It's been interesting to watch services transition to electronic billing (RescueNet Billing, in particular), moving their PCS/MedNec to the ePCR software, and "direct billing", in some bases, without billing department review. It's one thing for us to leave paper PCS' for the nurses at the hospital, having them fill them out on their own, and picking them up with the paperwork, but I don't understand how facility staff are expected to navigate multiple menus on the computer, to complete this documentation. 

I think we all know what the ideal solution is, but struggle to get there, when faced with electronic PCS forms, busy/lazy RNs, and inconsistent direction from management. 

I applaud AMR's statement, however frustrating it must be for RNs and EMS, but wonder if CMS just has bigger fish to fry, bigger issues than this, to investigate.


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## ZombieEMT (Feb 23, 2014)

If it is truthful, even if we have to "coach" them, it is not fraud. Many nurses do not understand the whole billing and/or EMS side of the medical field, so they do not know exactly what qualifies. For example, at mental health patient might be ambulatory and have no medical complaint, but required BLS due to them being a danger to themself or others. One of the approved people to fill out a medical necessity (at least in NJ) is a case worker/discharge planner, who is not always a nurse.

The company I work for has a TRT (transport coordinator) that is responsible for setting up transport and getting paperwork ready prior to the arrival of crews. Part of their job is ensuring that paperwork is filled out correctly so that the patient can be transported by appropraite means.


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## Angel (Feb 23, 2014)

ive had similar situations, but we don't have to do too much coaching as in 'fill this out' even though its not truthful. nurses are smart and want to get rid of their patient so at times they will fill in that the patient is 'nonambulatory,' even if they are, and will have no problems telling the patient walk to the gurney. it makes no sense and I consider it fraud but it falls on them because they put that on their own and its their signature. 

I would document truthfully because what my old company did was, make us sheet lift EVERY patient, even if they didn't need it *see above, because that justified the transport. THAT, to me, is fraud and I did not do it if it wasn't necessary and documented why.

Sometimes the only reason for the transport (if they weren't bed confined) would be 'v/s monitored for trending.'

its a half truth. IMO


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## ZombieEMT (Feb 23, 2014)

Angel said:


> ive had similar situations, but we don't have to do too much coaching as in 'fill this out' even though its not truthful. nurses are smart and want to get rid of their patient so at times they will fill in that the patient is 'nonambulatory,' even if they are, and will have no problems telling the patient walk to the gurney. it makes no sense and I consider it fraud but it falls on them because they put that on their own and its their signature.



If I was you, I would probably rethink that thought. Even though it is their signature, it is your company submitting the claim to the insurance. If you transport a patient that doesn't really require a stretcher then your company is still fraudulent. If you only document truth then personally you might be safe but the company is still fraud. Also, be careful. I know where I work, management expects us to check and make sure the form is correct and patient requires stretcher transport. If they don't, paperwork is wrong, or we are unsure we call. Nobody wants to loose their job and it does happen.


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## mycrofft (Feb 23, 2014)

Having been one of those folks who read similar forms at the receiving end (after they were filled out), here are some observations :

1. There are key phrases we would look for. If they were included it made it go faster. The trick is tell the truth. 

Big one: non-ambulatory needing transport or a wheelchair, means to meet a medical necessity such as an appointment, or to perform an "affair of daily living"/ADL such as going to the bathroom. GOing to church, going grocery shopping: FAIL.

2. Sometimes I would call people (Doctors' offices mostly) and do everything but send morse code to get them to use the magic phrase. 

Silly, but that's the game. We could not tell them where to look up CPT and HCPC codes themselves, which would have helped them plan and request care and money in a reasonable fashion; we were basically told to let them fail then deny them.

(PS: see hints above)
But TELL THE TRUTH


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## Kevinf (Feb 23, 2014)

Angel said:


> ive had similar situations, but we don't have to do too much coaching as in 'fill this out' even though its not truthful. nurses are smart and want to get rid of their patient so at times they will fill in that the patient is 'nonambulatory,' even if they are, and will have no problems telling the patient walk to the gurney. it makes no sense and I consider it fraud but it falls on them because they put that on their own and its their signature.
> 
> I would document truthfully because what my old company did was, make us sheet lift EVERY patient, even if they didn't need it *see above, because that justified the transport. THAT, to me, is fraud and I did not do it if it wasn't necessary and documented why.
> 
> ...



I've refused transport for patient's that didn't match the "reasons" on the medical necessity. I had one patient that was "bed-confined" as pretty much the sole reason for stretcher transport, yet I walked into his room to see him standing up and dressing himself before pushing his bed out of our way. Went right back to the nurses station and told them that we'd page our dispatch for a wheelchair van for the patient. As has been said, if you have reason to believe the reason for transport is untrue, don't be lulled into thinking it can't come back on you/your company.


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## medicdan (Feb 23, 2014)

Kevinf said:


> I've refused transport for patient's that didn't match the "reasons" on the medical necessity. I had one patient that was "bed-confined" as pretty much the sole reason for stretcher transport, yet I walked into his room to see him standing up and dressing himself before pushing his bed out of our way. Went right back to the nurses station and told them that we'd page our dispatch for a wheelchair van for the patient. As has been said, if you have reason to believe the reason for transport is untrue, don't be lulled into thinking it can't come back on you/your company.



That wouldn't be a reason to refuse transport in my systems, we would do the call, but make clear in the documentation the transport didn't meet medical necessity transport criteria. I know that my service has agreements for alternative payment (non-Medicare/Medicaid/Insurance), in some cases, from the ordering facility, private pay, or ACO/mobile integrated healthcare arrangements. Thats why we work hard to get the name of the staff calling to book the transport, and the staff signing the PCS.


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## mycrofft (Feb 23, 2014)

Kevinf said:


> I've refused transport for patient's that didn't match the "reasons" on the medical necessity. I had one patient that was "bed-confined" as pretty much the sole reason for stretcher transport, yet I walked into his room to see him standing up and dressing himself before pushing his bed out of our way. Went right back to the nurses station and told them that we'd page our dispatch for a wheelchair van for the patient. As has been said, if you have reason to believe the reason for transport is untrue, don't be lulled into thinking it can't come back on you/your company.



I can't speak for other agencies, but all we would do is deny funds and leave them to get their money any way they could. If we sensed certain providers had a pattern of this we could tell our boss an audit was needed. I have no idea what happened after that. No penalties or whatever; but, then again, we were a County, not the Feds.


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## Angel (Feb 23, 2014)

ZombieEMT said:


> If I was you, I would probably rethink that thought. Even though it is their signature, it is your company submitting the claim to the insurance. If you transport a patient that doesn't really require a stretcher then your company is still fraudulent. If you only document truth then personally you might be safe but the company is still fraud. Also, be careful. I know where I work, management expects us to check and make sure the form is correct and patient requires stretcher transport. If they don't, paperwork is wrong, or we are unsure we call. Nobody wants to loose their job and it does happen.




I don't work there anymore thankfully, but to be totally honest they don't care. their way around it was forcing us (with the threat of discipline or termination) to sheet transfer every patient-thus (im guessing) to insurance justifying the transport, because we never know if the patient can become weak and fall (load of BS). this was the expectation for every patient except psychiatric patients. I just documented it to cover my arse, even if the PCR reason for transport didn't match the PCS, ie if they were clearly ambulatory and the PCS said bed confined I would put vitals for trending or whatever the reason for transport was.

I would very much like to never work for an IFT company ever again...


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## Kevinf (Feb 24, 2014)

mycrofft said:


> I can't speak for other agencies, but all we would do is deny funds and leave them to get their money any way they could. If we sensed certain providers had a pattern of this we could tell our boss an audit was needed. I have no idea what happened after that. No penalties or whatever; but, then again, we were a County, not the Feds.



For any facility that we have a contract in place for, we'll do it as a BLS stretcher transport and the facility will simply have to pay the (contract) BLS rate if our documentation contradicts what's on the medical necessity form. For facilities not under contract we'll send a wheelchair van if things are sketchy on the medical necessity. If they still want to pay for an ambulance transport, that's on them.


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## unleashedfury (Feb 24, 2014)

Kevinf said:


> For any facility that we have a contract in place for, we'll do it as a BLS stretcher transport and the facility will simply have to pay the (contract) BLS rate if our documentation contradicts what's on the medical necessity form. For facilities not under contract we'll send a wheelchair van if things are sketchy on the medical necessity. If they still want to pay for an ambulance transport, that's on them.



We have a "advanced beneficiary notice" so if the bill is rejected by insurance we can send a bill that they are aware of based on the quotes they agreed to. More often than not most people accept the quote and others will chose wheel chair transport if they know they will have to pay for it.


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## Meursault (Feb 24, 2014)

unleashedfury said:


> We have a "advanced beneficiary notice" so if the bill is rejected by insurance we can send a bill that they are aware of based on the quotes they agreed to. More often than not most people accept the quote and others will chose wheel chair transport if they know they will have to pay for it.



Really? I thought CMS didn't like ABNs for ambulance services and specifically forbade them if the pt. could be transported safely by other means. 

I suppose that would still work fine for the privately-insured. Speaking of, can anyone help me understand medical necessity/billing for private insurers? At least CMS doesn't have any incentive to keep things opaque.

And doesn't that mean your employees could actually _*gasp*_ know how much things cost? How un-American!


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## mycrofft (Feb 24, 2014)

WHy not post prices on the side of the vehicles like a taxi?


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## Kevinf (Feb 25, 2014)

unleashedfury said:


> We have a "advanced beneficiary notice" so if the bill is rejected by insurance we can send a bill that they are aware of based on the quotes they agreed to. More often than not most people accept the quote and others will chose wheel chair transport if they know they will have to pay for it.



We actually just had a meeting where ABNs are being required for every transport because of this. They aren't going to fuss about it for contracted facilities too much, but we need to make double sure we get them for any residence or non-contract call.


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## titmouse (Feb 25, 2014)

Oh yes... the :censored: PCS (Physician Care Sheet) forms. I am required to obtain it. When the nurses decline to fill out it out, I write it out in my narrative and go on with my day.


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## NaptownEMT (Mar 7, 2014)

titmouse said:


> Oh yes... the :censored: PCS (Physician Care Sheet) forms. I am required to obtain it. When the nurses decline to fill out it out, I write it out in my narrative and go on with my day.



If we don't get the PCS filled out, we don't transport.


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## 18G (Mar 12, 2014)

A PCS form isn't optional. It's required for the claim to be processed and payment received. The hospital wouldn't want to lose money so why are they expecting your company to?

Ps I'm assuming you mean the form that indicates medical necessity for Medicare recipients?


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