# Did An Ambulance Company Take Taxpayers For A Ride?



## MMiz (Nov 5, 2009)

*Did An Ambulance Company Take Taxpayers For A Ride?*

It's one of the most profitable private ambulance companies in the state. The privately owned Murfreesboro Ambulance Service is at the center of a federal investigation into Medicare fraud.

The company transports critically ill patients to and from doctor's appointments, but federal investigators said it acted like an overpriced taxi service -- fraudulently billing Medicare more than $430,000.

"Did you get rich ripping off Medicare?" investigative reporter Ben Hall asked the owner of the company.

"I don't know as I ever got rich. We made a good living by working long hard hours, " responded owner Woody Medlock.

*Read more!*


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## rescue99 (Nov 5, 2009)

MMiz said:


> *Did An Ambulance Company Take Taxpayers For A Ride?*
> 
> It's one of the most profitable private ambulance companies in the state. The privately owned Murfreesboro Ambulance Service is at the center of a federal investigation into Medicare fraud.
> 
> ...



Things like this is routine practice among ambulance services as is poor reimbursement practices by insurance companies. I'd love for every EMT-Paramedic to be required to work in billing as a part of the EMS experience. It's a real eye opener.:unsure:


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## atropine (Nov 5, 2009)

Ofcourse they took the tax payers for a ride, thats what happens when you let the privates run things, is anyone really surprised here.


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## rescue99 (Nov 5, 2009)

atropine said:


> Ofcourse they took the tax payers for a ride, thats what happens when you let the privates run things, is anyone really surprised here.



Privates my tush! I live in a community which runs ALS and believe me, we pay twice! First, there i s the 3+ mils we pay annually for EMS / Fire service then the FD has the nerve to charge again!! It's an insurance scam, a public rip off and it needs to be stopped. Even though our primary income source comes from this fire department, I have always been extremely vocal about the FD double dipping scam.


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## RyanMidd (Nov 5, 2009)

I work for the private industrial EMS sector, and I know that I, as an employee, am fairly compensated.

What other billing goes on, I don't know. I'd rather keep it that way most of the time.


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## EMT.Hart (Nov 5, 2009)

RyanMidd said:


> What other billing goes on, I don't know. I'd rather keep it that way most of the time.



...agreed.


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## Aidey (Nov 5, 2009)

I don't know if that agency was 911 or IFT or both, but this is an example of a horrible catch 22 that ALL types of ambulances are in. 

_"A recent federal study indicated one fourth of all ambulance transports nationally did not meet Medicare requirements. That amounted to more than $400 million in improper payments."

_Duh. We all know that. What the article doesn't say is that the 4th medicare patient you pick up meets you in the entryway, bag in hand, complaining of elbow pain x1 week and REFUSES to consider going to the hospital any other way. They won't take a taxi, call a friend, or wait till the morning and call their bloody GP. They demand you take them, and that is that. 

Or the nursing home that calls at 3am for a patient with idopathic "toe pain", and when you show up the RN hands you a PCS form, filled out, and tells you that you are transporting the pt, end of? (not kidding, really happened). The crew spent 10 minutes explaining that "unable to stand due to toe pain" was not a justifiable reason for an ambulance because the patient could be transported via wheelchair van in the morning since toe pain is not an emergency situation. Needless to say, we lost, and the pt was transported. Who is going to be accused of fraud for that? My company or the RN? 

So now we have Medicare on one hand saying "you're committing fraud!" and on the other hand we've got our employers, physician sponsors, and EMS councils stating "You can't refuse to transport a patient". What on earth are we supposed to do? Until it is legal for us to refuse to transport someone how can Medicare say "if it doesn't meet requirements, don't transport".

I also have to mention that if all those runs didn't meet requirements, how come Medicare payed? If they can prove that 1/4 of all ambulance transports didn't meet requirements then how come they paid for them? It sounds like Medicare also needs to work on their billing to prevent paying out in the first place. 

I know that it is different when the person writing the report is intentionally falsifying what happened in order to make it meet requirements. I'm talking about the people not trying to intentionally defraud Medicare.


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## Shishkabob (Nov 5, 2009)

atropine said:


> Ofcourse they took the tax payers for a ride, thats what happens when you let the privates run things, is anyone really surprised here.



Right, because a service who does 70% EMS and 30% fire, but spends most of their annual budget on fire engines and fire supplies instead of new medical equipment isn't doing a disservice to their community.


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## atropine (Nov 5, 2009)

Linuss said:


> Right, because a service who does 70% EMS and 30% fire, but spends most of their annual budget on fire engines and fire supplies instead of new medical equipment isn't doing a disservice to their community.



I agree lucky were not one of those departments, we just updated our whole ambulance feet two years ago and gurneys


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## Shishkabob (Nov 5, 2009)

Right, because powered cots have such an impact on pt outcomes. 

How about putting that money towards more education so all your medics can interpret 12-leads amd do more interventions based off of such?


Or more intubation education?


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## atropine (Nov 5, 2009)

Linuss said:


> Right, because powered cots have such an impact on pt outcomes.
> 
> How about putting that money towards more education so all your medics can interpret 12-leads amd do more interventions based off of such?
> 
> ...



Why I need that money for my Cancun trips.


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## ah2388 (Nov 7, 2009)

for what its worth, i think the cots are an investment into the wellbeing of your employees

I agree that lifting technique is obviously important but I think everyone here will attest that sometimes it isn't enough...

That being said, I agree with your stance regarding more training towards personnel rather than spending money on other things that are used less often


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## flhtci01 (Nov 8, 2009)

I think you will see more cases like this.  There was a similar one not too far from here recently http://emtlife.com/showthread.php?t=15114

I had a IFT for a company that could realistically did not have a medical basis for the transport.  When I contacted dispatch with the information at the end of the run, I was told, "That sounds like a freebie, make it (the report) look like he needed ..."  

I left the company a short time after that.


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## mycrofft (Nov 8, 2009)

*When I was a case manager...and when I worked ambulance....*

As a case manager I could spot silly transports most of the time, but often when yo are a hundred cases in arrears and considering charges for ventilators, operations, etc., the ambulance trip slips by.

Having worked for two services, one completely private and another heavily subsidized, plus managed a two unit "fleet" in the Guard, , the cost of running an ambuance is quite high, especially when you consider insurance. Trip-based (X number of trips per month) averaging of amortization makes for higher costs for all. Time-averaged makes it more expensive for the users with longer calls. Charging strictly for level of care and equip/supply use yields horror stories about sixty dollar gauze sponges.

The tax-plus-fee deal works if there is no bilking. Stop responding the whole dept for EMS calls, the cost per run increase goes ballistic. Stop trying to use fees to discourage patients, but offer a less expensive alternative for getting to medical care. 

Did they rip off taxpayers? What was their intent? Does their financial picture exhibit _*personal*_ windfall profits? Or was any extra income put back into the corporation to better serve customers?


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## JCampbell (Nov 8, 2009)

atropine said:


> Ofcourse they took the tax payers for a ride, thats what happens when you let the privates run things, is anyone really surprised here.



"LET"???   Last I checked I live in a free country.


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## daedalus (Nov 8, 2009)

Aidey, 

At the company I previously worked for, we were able to refuse transport for nursing home transfers, dr. appointments, and the like if the patient did not meet medicare requirements which were printed on the back of our PCRs. If the patient did not meet criteria for transport but wanted to go by ambulance anyways they could pay up front. Upon hearing the price, most chose to call family to take them to their various appointments (people always expect something for nothing). Even if a nurse demanded the patient be transfered, it was out policy to refuse in non-emergency transports that did not meet medicare requirements. 

Now, there is a saving grace for some of these patients that lived in Los Angeles County. Los Angeles County actually opts to tax its citizens and spend some of that money on paying for ambulance transports for patients who do not meet criteria for medicare reimbursement. Typical LA Access transports included picking up "patients" in Lancaster and drive them down to Harbor City to a county hospital to receive their prescriptions or doctors notes, and than drive them back up tot he high desert. These transports were about 70 miles each way and the patients are ambulatory, AOX4, and in no acute distress. In fact, most of them could (and do) drive or have family that could drive them. These transports are handled by private companies who are paid to take these calls by the County.

I think the problem lies in that we just need to stop bringing people to dialysis or doctors appointments or back home in ambulances staffed with EMTs and paramedics. We are not trained to do the job, and the use of emergency vehicles is inappropriate. Lets start using litter vans and CNAs.


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## daedalus (Nov 8, 2009)

flhtci01 said:


> I had a IFT for a company that could realistically did not have a medical basis for the transport.  When I contacted dispatch with the information at the end of the run, I was told, "That sounds like a freebie, make it (the report) look like he needed ..."
> 
> I left the company a short time after that.



This is typical in the Los ANgeles area.


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## triemal04 (Nov 8, 2009)

daedalus said:


> *I think the problem lies in that we just need to stop bringing people to dialysis or doctors appointments or back home in ambulances staffed with EMTs and paramedics.* We are not trained to do the job, and the use of emergency vehicles is inappropriate. *Lets start using litter vans and CNAs*.


Nooooo...let's start using litter/wheelchair vans and NON-MEDICAL drivers.  Seriously, how many of these people actually need someone (with more training than maybe a CPR card) watching over them?  Answer: very, very few.  If someone needs a ride to a dialysis/MD's appointment and that's all...get them an appropriate taxi.  Medical transport shouldn't be used unless it truly is needed, and, as is happening here, if it's used wrongly, dealt with harshly.  

One of the ways to start changing the system is to crack down on the abuses and unnecessary uses of it.


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## daedalus (Nov 8, 2009)

triemal04 said:


> Nooooo...let's start using litter/wheelchair vans and NON-MEDICAL drivers.  Seriously, how many of these people actually need someone (with more training than maybe a CPR card) watching over them?  Answer: very, very few.  If someone needs a ride to a dialysis/MD's appointment and that's all...get them an appropriate taxi.  Medical transport shouldn't be used unless it truly is needed, and, as is happening here, if it's used wrongly, dealt with harshly.
> 
> One of the ways to start changing the system is to crack down on the abuses and unnecessary uses of it.


Not a bad idea, but its not like we would have to pay the CNAs a whole lot anyways. They are the nursing equivalents of EMT-Basics.


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## triemal04 (Nov 8, 2009)

daedalus said:


> Not a bad idea, but its not like we would have to pay the CNAs a whole lot anyways. They are the nursing equivalents of EMT-Basics.


That doesn't matter (it's not like the average wheelchair van EMT or strict non-emergency transport EMT get's paid much either); they could work for $0.25/hr and it still wouldn't be right.  It's not a pay issue, but a misuse/abuse of a resource issue.  While there are some people who, because of a chronic condition or maybe some other reason might need medical supervision during a scheduled trip to an appointment or discharge from a hospital, the vast majority don't.  So why do we insist on using medical personnel (and this would include CNA's if they were used, or RN's, docs, anything) in an unnecessary fashion?  And fraudulent charging people/gov't for it?

I don't know if would violate JACAHO/EMTALA or any state/local/federal statutes if someone was sent out of the hospital, or to the hospital/appointment with non-medical personnel; I doubt it in most situations.  If it does...then it needs to be changed.  People should not be stuck with something that is unnecessary, and then billed for it.


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## flhtci01 (Nov 9, 2009)

triemal04 said:


> ...let's start using litter/wheelchair vans and NON-MEDICAL drivers.  Seriously, how many of these people actually need someone (with more training than maybe a CPR card) watching over them?  Answer: very, very few.  If someone needs a ride to a dialysis/MD's appointment and that's all...get them an appropriate taxi.  Medical transport shouldn't be used unless it truly is needed, and, as is happening here, if it's used wrongly, dealt with harshly.
> 
> One of the ways to start changing the system is to crack down on the abuses and unnecessary uses of it.



One SNF here is really good about this.  They send a CNA with the resident on the appropriate non-medical transportation.

Beats tying up a rig and personnel to transport someone to the Dr.'s office for 'a quick Foley change' that ends up taking almost an hour because the Dr. was busy.


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## mycrofft (Nov 11, 2009)

*MAybe there needs to be a new category of service, a laydown van?*

Carries a litter but the pt is not critical or emergent. Try riding in a wheelchair in a van sometime. Imagine you have old guy pains and aches and fear of others driving etc. Imagine you are mostly in bed in the home then tossed into a van or taxi.
Non-emergenct transports are a good intro to PATIENT care for hotshot young rope-swinger EMT's.

(Lancaster to Wilmington? Oh my achey taxbracket!).


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## JonTullos (Nov 11, 2009)

triemal04 said:


> One of the ways to start changing the system is to crack down on the abuses and unnecessary uses of it.



You hit the nail right on the head... but that's a tough act when you have medical directors and others saying you have to transport those patients or else.  It's happening in I'd say 90% of EMS systems around the world.


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## Aidey (Nov 11, 2009)

JonTullos said:


> You hit the nail right on the head... but that's a tough act when you have medical directors and others saying you have to transport those patients or else.  It's happening in I'd say 90% of EMS systems around the world.



Exactly. You can't always blame one person for the abuse. We've got the LTC RN or LPN or even CNA who sees something and goes "OMG!!! AHHHHH!" and calls the on call doc who then automatically says "transport the pt". We get there, realize the patient doesn't need to go (and in some cases doesn't WANT to go) but we have our supervisor, company and medical director all saying "YOU WILL TRANSPORT WITHOUT QUESTION!". _(95 yo F with severe dementia. Brand new (1 week on job) RN called for transport because "pt isn't acting right". CNA who has worked with pt for 2 years states that pt is acting perfectly normal for herself and she can't convince the RN that it's normal for the pt to stare off into space all the time.) _

We also have patients that demand to the RN to be transported and the RN doesn't want to argue with them so they send them out even though it doesn't meet medical necessity for transport in an ambulance to an ED. _(Ingrown toenail 2 weeks old, pt saw GP who put them on antibiotics and scheduled a toenail removal a couple days in the future.) _

There are going to have to be changes on multiple levels in order to make any impact on the number of transports that don't meet necessity. 

What is a problem in my area is that there are no wheelchair vans or stretcher transport vehicles available at night. Well, there are a couple of wheelchair vans, but they are connected to the dialysis clinics and aren't for general use. 

Anyway. Under Medicare's ambulance transport necessity guidelines if the pt can go by wheelchair van, lack of a van DOES NOT make ambulance transport necessary and it isn't covered. The CMS necessity paperwork says that right on it, and it is very clear. 

So my company is stuck. The hospitals discharge people who can't go by POV and since there isn't a van, they call us. The transport doesn't meet necessity guidelines, but we have to transport the patient, even knowing we aren't going to get reimbursed for it. Sometimes we even end up taking pts who could go POV. 

Example, pt is ambulatory with a walker. Walker wasn't brought to the hospital in the ambulance. Pt has no friends/family to drive her back to nursing home. Taxi driver won't assist patient in walking, nursing home staff won't assist the patient while the pt is outside the building. Pt can't get from taxi to building on her own. 

I never did figure out why the staff couldn't just leave the pts walker out on the sidewalk. The issue ended up being resolved when the hospital sent a walker with the pt in the taxi, and our supervisor went and picked it up and brought it back. 

Ok, I'm done ranting. Sorry, had one of those stupid nights at work last night that reinforced the fact that the system is broken so I'm a little on my soap box right now.


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## So. IL Medic (Nov 15, 2009)

atropine said:


> Ofcourse they took the tax payers for a ride, thats what happens when you let the privates run things, is anyone really surprised here.



First response - screw you.

There are four ambulance services in my area. Two municipals, one semi-private under county supervision and subsidy, one completely private. Three of those services have been in trouble for medicare and billing fraud. Two have former administrators in federal prison.

Guess what, the private has been in service for 25 years and never once has had any legal problems. EVER. No fraud. No taxpayer money wasted because of 'if we don't spend the money, we can't get a budget increase next year' crap.

We, the private, provide the 911 response for over three counties with  quality 24/7 ALS service without shuffling up to the tax money trough or bilking medcare.

So the second response is...screw you.


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## VentMedic (Nov 15, 2009)

flhtci01 said:


> One SNF here is really good about this. They send a CNA with the resident on the appropriate non-medical transportation.
> 
> Beats tying up a rig and personnel to transport someone to the Dr.'s office for 'a quick Foley change' that ends up taking almost an hour because the Dr. was busy.


 
That is an excellent idea since CNAs and PCTs should be staffing the ambulances for IFT since these patients need providers familiar with taking BPs, moving various types of patients with special needs or accessories and who are comfortable talking with patients.  These patients generally do not need first aid or someone who is not familiar with the care of special needs and elderly patients.   CNAs and PCTs have many more patient contact hours to their experience and that would be a good argument to make them the better choice.   At least the patients/insurances might get a little more care for the fees charged. 



Aidey said:


> Exactly. You can't always blame one person for the abuse. We've got the LTC RN or LPN or even CNA who sees something and goes "OMG!!! AHHHHH!" and calls the on call doc who then automatically says "transport the pt". We get there, realize the patient doesn't need to go (and in some cases doesn't WANT to go) but we have our supervisor, company and *medical director all saying "YOU WILL TRANSPORT WITHOUT QUESTION!"*. _(95 yo F with severe dementia. Brand new (1 week on job) RN called for transport because "pt isn't acting right". CNA who has worked with pt for 2 years states that pt is acting perfectly normal for herself and she can't convince the RN that it's normal for the pt to stare off into space all the time.) _
> 
> We also have patients that demand to the RN to be transported and the RN doesn't want to argue with them so they send them out even though it doesn't meet medical necessity for transport in an ambulance to an ED. _(Ingrown toenail 2 weeks old, pt saw GP who put them on antibiotics and scheduled a toenail removal a couple days in the future.) _


 
So as an EMT you now know more than a doctor?  You now have the right to determine who goes to the hospital and who doesn't or who is not worthy of medical care like a 95 y/o.  Maybe we should just tell them to die already so you won't be bothered.  

Maybe you should also do a little checking on patient's rights and the rules of justification for transport.  It is on the internet and in the LTC facilities P&P books for you to check out.   It seems you are spouting off from personal dislike of patients and the system rather than actual knowledge of the process and documentation that goes along with it.   But then all that semantics stuff is such a mystery.  



> Example, pt is ambulatory with a walker. *Walker wasn't brought to the hospital in the ambulance.* Pt has no friends/family to drive her back to nursing home. Taxi driver won't assist patient in walking, nursing home staff won't assist the patient while the pt is outside the building. Pt can't get from taxi to building on her own.


 
Do you know how many times an ambulance refuses to take a walker or some other necessary piece of equipment?  

Don't just put the blame on the NH or the patient. 

If you don't like your system, you could always puts your complaints in writing and start a paper trail of possible improvements.  If you think the NH is committing wrongs by sending patients to the hospital, write it up and send it to the state agency overseeing that facility.  However, you had better be certain you can prove everything you say.   Make sure you are not just talking because you don't like transporting calls you believe are BS that waste your time and not some real cool trauma.


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## Aidey (Nov 15, 2009)

VentMedic said:


> So as an EMT you now know more than a doctor?  You now have the right to determine who goes to the hospital and who doesn't or who is not worthy of medical care like a 95 y/o.  Maybe we should just tell them to die already so you won't be bothered.



Vent did you even read the example of the situation? The CNA familiar with the patient repeatedly told us she was acting normal, her vitals were all within the ranges that her daily vitals were for the last week, and yet the RN insisted the patient wasn't acting right because "people don't just stare off into space like that". 

 Do you really think it is impossible for an RN to overreact? Or for an RN to exaggerate a patients condition to a doctor in order to receive orders to send out a patient that they flat out admitted to the ambulance and fire personnel "I'm just sick of his whining and don't want to deal with him anymore". It has nothing to do with the right to go to the hospital or not, it's about NEED and the fact that need is a very very subjective term at some facilities, and because we (the field providers) are not allowed to question the staff at all the system is abused. 

Here is another example just to make it even clearer. Where I am we have a fairly through DNR form that includes things like if the patient wants antibiotics, or tube feeding, or dialysis etc. In one of the categories it states "EMS personnel will contact medical control to determine if transport is necessary". This is the "palliative care" box, where the pt or their representative has chosen to forgo any additional life sustaining treatment, and care is strictly to be palliative in nature. We are not allowed to do anything for these patients but transport them and give them O2. No IV, no airway of any sort, no life sustaining medications etc. 

Now, these patients get sent out a lot for various reasons. If the RN has already called their doc we let it go, but the couple of times we've called medical control as legally required to do on the form? The RNs have complained to our company. 

The patient in that case has elected no advanced care and that medical direction should determine transport necessity, so if we call them are the evil EMT's still the ones denying them their right to the hospital?


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## VentMedic (Nov 15, 2009)

Aidey said:


> Vent did you even read the example of the situation? The CNA familiar with the patient repeatedly told us she was acting normal, her vitals were all within the ranges that her daily vitals were for the last week, and yet the RN insisted the patient wasn't acting right because "people don't just stare off into space like that".


 
CNA assessment? Yeah that will protect the RN's license about as much as an EMT telling the Paramedic how to treat a patient in court. Are you also aware of the documentation that must be provided by the RN during his/her shift assessment? If it deviates from the documentation done by the earlier shift, that RN must also justify why something was not done. As well, each time a patient is transported, extensive documentation must be filled out and filed for any inspections by the insurances and state agencies. 



Aidey said:


> Do you really think it is impossible for an RN to overreact? Or for an RN to exaggerate a patients condition to a doctor in order to receive orders to send out a patient that they flat out admitted to the ambulance and fire personnel "I'm just sick of his whining and don't want to deal with him anymore". It has nothing to do with the right to go to the hospital or not, it's about NEED and the fact that need is a very very subjective term at some facilities, and because we (the field providers) are not allowed to question the staff at all the system is abused.


 
Or is it to error on the side of caution? It is of no benefit for an RN to get boggled down in more transfer paper work when he/she may already have 5 - 10 patients transferring here and there for various reasons. The RN is also overseeing the care of at least 30 patients. You have only patient at a time. You are now trying to judge and second guess someone who specializes in LTC and who manages to care for over 30x more patient than you do at one time. I can definitely see where a nurse might also want to see a patient gets the medical treatment they feel necessary. We do lab work and/or CT Scans all day and all night long at the hospital for AMS. 



Aidey said:


> Here is another example just to make it even clearer. Where I am we have a fairly through DNR form that includes things like if the patient wants antibiotics, or tube feeding, or dialysis etc. In one of the categories it states "EMS personnel will contact medical control to determine if transport is necessary". This is the "palliative care" box, where the pt or their representative has chosen to forgo any additional life sustaining treatment, and care is strictly to be palliative in nature. We are not allowed to do anything for these patients but transport them and give them O2. No IV, no airway of any sort, no life sustaining medications etc.
> 
> Now, these patients get sent out a lot for various reasons. If the RN has already called their doc we let it go, but the couple of times we've called medical control as legally required to do on the form? The RNs have complained to our company.
> 
> The patient in that case has elected no advanced care and that medical direction should determine transport necessity, so if we call them are the evil EMT's still the ones denying them their right to the hospital?


 
A patient also shouldn't have to suffer from a broken extremity or be in pain. Unfortunately some patients may require an assessment from someone other than the RN to determine the patient has a condition that meets the specifications in the DNR. Few doctors are going to give "comfort care" orders for a morphine drip for end of life without some verification. The line between a DNR and "palative" care must be well documented. But, even still, no patient deserves to suffer just believe the EMTs believe the patient is not worthy of transport to determine proper care and have the necessary acceptance with the proper paper work into hospice care even it is back at that same LTC facility. You really must understand the legal situations as a whole for each patient. Sending a patient to the ED for treatment of a purely reversible problem that is causing discomfort is not the same as putting that patient on dialysis or a ventilaor. Comfort care patients are also transported to the ED for a re-evaluation of their pain medications if they suffer a reaction of some type or need them adjusted for enhanced comfort. Again, no patient deserves to suffer just because of how you interpret a piece of paper if a doctor, patient or family member sees otherwise and does not want that patient to suffer. The DNR can still be honored but humanely. Patients don't always die quickly and quietly like in the movies.

Again, if you feel you have a case for system abuse against the RN, the LTC facility and its medical director, do the proper documentation and submit it in writing.


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## Vizior (Nov 15, 2009)

Vent, I think you are taking the thoughts out of the context that they are presented.  It is nice to think that every health care provider has only the patient's best interests in mind, but I think we all know of providers that will do their best "to get rid of a patient," whether in EMS, SNF, or the hospital.  I believe the issue that they are presenting is that if a BLS unit is called to a SNF for a transport to the ER for an evaluation of a non-acute problem.  Whether it is because the patient has a physician's appointment later that day or is simply being difficult for the staff at the SNF, it becomes our responsibility to treat and transport this patient.  The same holds true with a hospital discharge, and the only recourse we are left with is to report such incidents to your immediate supervisor and document every patient report factually.  While it may be that they are being cautious, or picking up on something that we are missing in our assessment, it should be followed through with to prevent abuse to the system and not given the benefit of the doubt.  If someone were unsure of how I handle patient refusals or another similar incident I would certainly expect them to report it to their supervisor and have it checked into.  

On an earlier note you recommended CNAs being used to staff interfacility transport 



> That is an excellent idea since CNAs and PCTs should be staffing the ambulances for IFT since these patients need providers familiar with taking BPs, moving various types of patients with special needs or accessories and who are comfortable talking with patients. These patients generally do not need first aid or someone who is not familiar with the care of special needs and elderly patients. CNAs and PCTs have many more patient contact hours to their experience and that would be a good argument to make them the better choice. At least the patients/insurances might get a little more care for the fees charged.



I did a little searching and did not find a detailed curriculum for a CNA.  The best I found was the Nevada requirements for a CNA, stating that it was 75 hours(with their required A+P being within the course as is similar to the mode of teaching as an EMT-B).  Is there a national curriculum, or any kind of documentation that you can provide that demonstrates why a CNA would be better suited to transport work than an EMT?  Perhaps we would be better off working to amend the EMT-B curriculum or adding better education at the company level to include more time educating about the special needs that some of these patients may have during an IFT.


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## triemal04 (Nov 16, 2009)

VentMedic said:


> That is an excellent idea since CNAs and PCTs should be staffing the ambulances for IFT since these patients need providers familiar with taking BPs, moving various types of patients with special needs or accessories and who are comfortable talking with patients.  These patients generally do not need first aid or someone who is not familiar with the care of special needs and elderly patients.   CNAs and PCTs have many more patient contact hours to their experience and that would be a good argument to make them the better choice.   At least the patients/insurances might get a little more care for the fees charged


And another fallacy.  On a role recently it seems...  Some CNA's may be better suited to transporting pt's of this nature, some won't; the same goes for taking vitals, amount of pt contact (with that pt or in general), lifting/moving, etc etc.  Simply giving someone a title does not automatically mean that they are the best person for the job; would have thought you'd know that.  Oh wait...nevermind.  CNA's have less training than even an EMT-B; again, a title does not make you the right person for the job.  Though I will agree if the nursing home has it's own transportation available sending someone FROM THAT NURSING HOME with the pt would be more appropriate and a great idea, as long as the pt actually needed that level of care.  Of course, if non-emergency transport services starting using CNA's instead of EMT's in general...well...you'd just see the same type of issues that are happening now, just with CNA's instead.  Lose lose situation.  Better to fix the problem than pass it off to someone else.


VentMedic said:


> Do you know how many times an ambulance refuses to take a walker or some other necessary piece of equipment?
> 
> Don't just put the blame on the NH or the patient.


Blame aside (didn't notice anyone placing blame anyway), do you really think that it's appropriate to send that particular pt in an ambulance and then bill medicare for it?  Wouldn't it be better to have an appropriate type of transport available to them?


Aidey said:


> Vent did you even read the example of the situation? The CNA familiar with the patient repeatedly told us she was acting normal, her vitals were all within the ranges that her daily vitals were for the last week, and yet the RN insisted the patient wasn't acting right because "people don't just stare off into space like that"?


No, she didn't, and often doesn't, and/or goes off on tangents.  This most recent string of vitriol, fallacies and anger is rather amazing though.  Besides, don't you know that only those of us in EMS can make mistakes or do wrong?  Everyone else is exempt.


VentMedic said:


> Or is it to error on the side of caution? It is of no benefit for an RN to get boggled down in more transfer paper work when he/she may already have 5 - 10 patients transferring here and there for various reasons. The RN is also overseeing the care of at least 30 patients.


No, some RN's may be involved in the care of that many pt's.  Unless you have been to the nursing home in questions, you don't know.  Remember, making blanket statements about abilities, duties, etc is often a bad idea.  Not to mention that you seem to be implying here that it is ok to ship a pt elsewhere, even if it's not needed, just to lighten the load, so to speak.  Dumping problems on other people is not the answer.


VentMedic said:


> A patient also shouldn't have to suffer from a broken extremity or be in pain. Unfortunately some patients may require an assessment from someone other than the RN to determine the patient has a condition that meets the specifications in the DNR. Few doctors are going to give "comfort care" orders for a morphine drip for end of life without some verification. The line between a DNR and "palative" care must be well documented. But, even still, no patient deserves to suffer just believe the EMTs believe the patient is not worthy of transport to determine proper care and have the necessary acceptance with the proper paper work into hospice care even it is back at that same LTC facility. You really must understand the legal situations as a whole for each patient. Sending a patient to the ED for treatment of a purely reversible problem that is causing discomfort is not the same as putting that patient on dialysis or a ventilaor.


And often times the pt is not in any distress; in fact they are quite comfortable where they are, and yet we are there because "they just aren't right today."  This despite the fact that their advance directives indicate comfort care only, they are not in discomfort, and the forms we use even indicate they should NOT be transported unless their COMFORT needs cannot be met at their current location.  And yes, I have taken it up with both the sending MD and my medical control when that MD wasn't available, and yes, often the pt has stayed there and been happy to do so.

Face it venty, it's not just people in EMS who make mistakes and do things that are not in the best interests of the pt; it happens at ALL levels much as you want to deny it.  And, when the mistake and/or inappropriate care is so blatant, it's easy for someone at any level to see it.

Perhaps you should calm down; this recent string is...disturbing even from you.


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## Aidey (Nov 17, 2009)

VentMedic said:


> That is an excellent idea since CNAs and PCTs should be staffing the ambulances for IFT since these patients need providers familiar with taking BPs, moving various types of patients with special needs or accessories and who are comfortable talking with patients.



While I can see where you are coming from about the special equipment, most of the facilities I've been in around here use NIBP. I don't know how common this is in other places, but at least around here I don't think that the CNAs that work in the facilities have a lot of recent experience auscultating BPs.


As for everything else, I have to say Vent, I really don't feel you are listening to me at all.

This thread was originally about fraud and Medicare. The fact is that 1/4 of all transports Medicare was billed for were determined not to meet medical necessity guidelines. Something is wrong with the system if that many people are being sent by ambulance that don't need to be. 

The PCS forms we use clearly state the medical necessity guidelines on them, and have examples of what does and doesn't meet necessity. This isn't about RNs vs Paramedics, but about the accurate representation of a patient's condition and the blatant disregard of the guidelines in some cases. 

I used a couple of examples of pts that either myself or a coworker has transported to illustrate cases where pts were transported that didn't meet CMS's guidelines. Instead of a discussion leading from this, I was basically told that paramedics have no right to question a RN, and that RNs are always right and never send patients in an ambulance that don't need it. The fact that 1/4 of all transports didn't meet Medicare guidelines indicates that somewhere someone else thinks that some of these patients didn't need an ambulance either.

I never once stated that any of the patients in my examples didn't need care, but rather I was trying to illustrate cases that didn't meet medical necessity for transport by an ambulance to an ER. Look at the case of the 95 yo with dementia. Was transport to the ER really in her best interest? Is it possible she would have been better served by being assessed by her general practitioner who knows her, and who knows her baseline? 

Vent, you seem hell bent on thinking that the only reasons people don't want to transport some of these patients is because they are lazy uneducated jerks who don't give a rats tail about the patients they treat. 

Have you ever considered we don't want to transport because we care about the patient and we realize the impact that non-medically necessary transports have on the big picture? 

In my case, I work nights, so when I do one of these runs the patient has to deal with strange people coming in the middle of the night and waking them up, bringing them into a hospital ED, where they will wait for hours, see a doctor they don't know, be subjected to a ton of tests, be exposed to infections and noise and a lot of stimuli they aren't used to and then discharged home. How is that better than taking a wheelchair van or POV ride to their regular doctor, whom they know and who knows them? What about a portable chest x-ray for someone with a cough and normal vitals rather than a transport to the ED for a x-ray. How can that much disruption for the patient be considered the best care?


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## VentMedic (Nov 17, 2009)

Aidey said:


> While I can see where you are coming from about the special equipment, most of the facilities I've been in around here use NIBP. I don't know how common this is in other places, but at least around here I don't think that the CNAs that work in the facilities have a lot of recent experience auscultating BPs.


 
Who do you think does the vitals in a LTC facility? One RN can not do it all. Look at the numerous threads we have on the EMS forums about EMTs not understanding the basics of BPs. Sit in any busy ED, listen to report and read the PCRs of the EMTs bringing in NH patients. I would say many of the numbers or fudged at best because some EMTs act as if they don't want to get close enough to the patient to check for vitals. This again just reflects on the poor training in the U.S. system. 



Aidey said:


> As for everything else, I have to say Vent, I really don't feel you are listening to me at all.


 

This thread was originally about fraud and Medicare. The fact is that 1/4 of all transports Medicare was billed for were determined not to meet medical necessity guidelines. Something is wrong with the system if that many people are being sent by ambulance that don't need to be. [/quote]

[/quote]

What have I repeatedly told you? Obviously from what you have stated, everyone except the EMTs are dumb as doggie poo that care for patients. If you feel there is blatant fraud, file the necessary reports to the state. Unless you who have personally seen all the abuse doesn't do anything, who else will? You criticize all the other healthcare professionals who are putting their license on the line by determining a patient's trip to the hospital when you yourself don't have the courage to file the reports. 



> Vent, you seem hell bent on thinking that the only reasons people don't want to transport some of these patients is because they are lazy uneducated jerks who don't give a rats tail about the patients they treat.
> 
> Have you ever considered we don't want to transport because we care about the patient and we realize the impact that non-medically necessary transports have on the big picture?


 
Do you have personal knowledge of the lab results and other tests done? Have you seen what new meds their physician will later prescribe to better manage their BP, diabetes or UTIs? If you have all of this knowledge and can maky a case, do the paperwork. 



> In my case, I work nights, so when I do one of these runs the patient has to deal with strange people coming in the middle of the night and waking them up, bringing them into a hospital ED, where they will wait for hours, see a doctor they don't know, be subjected to a ton of tests, be exposed to infections and noise and a lot of stimuli they aren't used to and then discharged home. How is that better than taking a wheelchair van or POV ride to their *regular doctor*, whom they know and who knows them? What about a portable chest x-ray for someone with a cough and normal vitals rather than a transport to the ED for a x-ray. How can that much disruption for the patient be considered the best care?


 
Many of these patients are not under the care of their private doctor once they become institiutionalized. Do you know how many patients do go by WC van? This is just like the EMTs who think they are the only ones that do dialysis transports. If they actually say the total number of patients at the dialysis clinics and those that do come by other means of transportation, they would realize that the 200+ dialysis patients we see in our center is alot more than the 1 or 2 they transport each day. And that is just our little center. There are others larger.

Geriatric and long term care are very specialized areas that few in EMS get any education about.  Maintaining their care and health is not as easy as you think.  Too often we see those that are brought in too late to reverse their rapid decline as it doesn't take long for sepsis to be overwhelming once that temp spikes.  You've gotta wonder how long they suffered and how many hoops the NH had to jump through to get that patient transported including the agruing with the EMTs.


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## Aidey (Nov 17, 2009)

VentMedic said:


> Who do you think does the vitals in a LTC facility? One RN can not do it all. Look at the numerous threads we have on the EMS forums about EMTs not understanding the basics of BPs. Sit in any busy ED, listen to report and read the PCRs of the EMTs bringing in NH patients. I would say many of the numbers or fudged at best because some EMTs act as if they don't want to get close enough to the patient to check for vitals. This again just reflects on the poor training in the U.S. system.


 
Vent, this has NOTHING to do with what I said! I KNOW one RN can't do it all. My point was simply that the CNAs who do the vitals may not be any better at taking BPs than an EMT or Paramedic because the CNAs might do all of their BPs with an NIBP. 


You really still are not listening to me at all, and I give up. It's obvious that you aren't going to listen to me or anyone else. Most of your replies have nothing to do with what I've actually said. It is impossible to have a discussion when one side is totally focused on repeating their agenda that all Paramedics and EMTs are morons who don't know anything and can't do anything right and everyone else is perfect and knows everything.


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## VentMedic (Nov 17, 2009)

Aidey said:


> You really still are not listening to me at all, and I give up. It's obvious that you aren't going to listen to me or anyone else. Most of your replies have nothing to do with what I've actually said. It is impossible to have a discussion when one side is totally focused on repeating their agenda that all Paramedics and EMTs are morons who don't know anything and can't do anything right and everyone else is perfect and knows everything.


 

It is obvious that you don't want to hear what I have to say.

There are laws for elder abuse, compliance and fraud.  Instead of just criticizing everyone in healthcare other than EMTs, do the paper work and file the complaint.  However, once you do you may realize there is a lot more to patient care than what you see in the 15 minutes you are with a patient.  But, if you believe that NH and their doctors are ripping everyone off and abusing the elderly in the middle of the night by making them go to the ED, file the reports with your accusations.   The next time an ED doctor or nurse also agrees with you, ask them to file a report with you.  However, I can bet they will then say "gotta see what the lab results are and look at the patient's history and talk to the referring physician".    Some complain but in reality they know that geriatric and long term care patients are difficult to medically manage.

But again, if you feel a patient or the system is abused, report it in writing to the appropriate agencies.  



> You really still are not listening to me at all, and I give up. It's obvious that you aren't going to listen to me or anyone else. Most of your replies have nothing to do with what I've actually said. It is impossible to have a discussion when one side is totally focused on repeating their agenda that all Paramedics and EMTs are morons who don't know anything and can't do anything right and everyone else is perfect and knows everything.


 
Not once did I call you a moron or anyone else here.

However, I do question those who have 110 hours of first aid training that talk a tall talk about how wrong RNs and MDs are including their own medical directors when they tell them to transport a patient to the hospital.  

However, it still stands, report abuse but be prepared to justify your reasons with solid documentation and not just because you believe a nursing home call is BS and granny do need not doctor.


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## Number1Monkey (Dec 5, 2009)

Linuss said:


> Right, because a service who does 70% EMS and 30% fire, but spends most of their annual budget on fire engines and fire supplies instead of new medical equipment isn't doing a disservice to their community.



Hate to choose sides but... agreed.


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## rescuepoppy (Dec 6, 2009)

Do ambulance companies commit fraud to make a profit? Yes some do. it does not matter whether they are private or public. Some hospitals do as well as do nursing homes, home health agencies, and any other company that bills medi-care,insurance companies,and angencies that pay for patient care. I am not saying that all or most do but some do, have, and will continue to do so.  This is not meant as a slam toward any health care giver, but aimed toward the powers in higher places that have became greedy and are taking advantage of the systems to make bigger profits

   This is a problem that will continue to go on until someone comes up with a way to stop it. I do not know what the answer is or if one is around. As I stated I am not aiming this at the care providers but at the people who are more comcerned about profit over the care factor.


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