Ask Billing Questions Here!

[BillingSpecialist]

How do you collect from foreign nationals who are visiting the US, but end up using EMS services? Particularly those who neglect to take out travel insurance (not mandatory for travel to the US).

These are the worst! There isn't a whole lot you can do with them. Because is would be very costly to go after them for their bill. There are collection agencies who claim they can collect on these foreign accounts, but I have yet to find one who actually collects anything! Unfortunately.....situations like these will more than likely result in a bad debt write off!

 

[Aprz]

I live in the San Francisco Bay Area, California. I was taught the "10 presumptive criteria for medicare".

Unconscious or shock
Emergency (ie car accident)
Restraints
Immobilized or c-spine
Hemorrhage
Bed bound*
Oxygen
Stetcher
Stroke
Respiratory or cardiac

*bed bound by itself wasn't a good enough reason by itself

And these were reasons that could be used to bill medicare for "why should they go by ambulance".

Companies require a copy of the patient's psychiatric hold (eg 5150) or advance directives (eg DNR) attached to the PCR. The original stays with the patient.

My question is if a patient is on a psychatric hold, but you felt they did not require restraints and you did not transport them with restraints on, is that still billable as BLS? What if your company has policy requiring that the patient be transported with restraints, but both you and the sending physician/RN felt the patient doesn't require it? In addition to this question, what about patient's that require an ambulance for special position or using some sort of wedge (eg bed ulcers, post hip replacement requiring a wedge, post total knee replacement). Supposedly no special position for the patient with an ulcer, and both the hip replacement requiring a wedge or total knee replacement patient want to walk to the gurney and the sending physician/RN says it's OK for them to do it. Does that still get billed as BLS?

Is a DNR a criterion for "why should they go by ambulance"?

If so, are there are things that are like this that are listed in the "10 presumptive criteria for medicare"?

What about people who pretty much require rapid transport to a facility (eg dissecting aneurysm), could you document the reason as "rapid transport" as a reason for why they should go by ambulance?

Thank you.

 

[BillingSpecialist]

No, a DNR alone would not fit the criteria for a reason to be transported by ambulance. Just because you have a DNR doesn't meant that it would be unsafe to the pt's condition to go by other means. I would really depend upon what else was going on with the pt. And yes, they should've know that if the pt has a DNR then you should obtain a copy of it. The pt is goig to be in your truck, and could crash, having that DNR is very important!

The 5150, yes that would qualify a pt transport. The 5150 was issued because someone felt the patient was of harm to them-self or to others. Of course it would require documentation on the EMTs part as to what's going on with the pt. With or without restraints shouldn't deem it "unbillable," the patient can be a harm to themself or to others & not necessarily "need" to be restrained. If your company has a policy in place that a pt w/a 5150 requires restraints, then I'm afraid you would have to do it. Maybe suggest to them that it be revised to state "unless EMT and/or physician feel it wasn't necessary."

For the special position/wedge placement transports, if the pt is being wheeled in a wheelchair to the gurney & then walking from the chair to the gurney, that should be ok. You could document that one like "pt being transported s/p total hip replacement. able to walk from w/c to gurney with assistance but no able to stand for long periods. must be transported laying down with wedge placement on side" Document it well & obtain a good medical necessity from the doctor!

The "rapid transport" reason is not a very good reason alone. The thing to remember is to document well! The trip will be considered medically necessary as long as the pt cannot go to a facility by other means without it being harmful to their health. If going by other means would be harmful to their health, then you need to document those reasons.

Here's a link to the Transportation manual from CMS http://www.cms.gov/Regulations-and-Guidance/Guidance/Manuals/downloads/bp102c10.pdf Maybe it will help you.

 

[BillingSpecialist]

Any body got any questions? This threads been kind of quiet for awhile.

 

[Brandon O]

Which insurances, or in what situations, will automatically pay for round trips (to appointments etc)? Versus requiring separately medical necessity statements each way?

 

[DrParasite]

They won't always pay for a trip to the ER, it really depends on what their complaints are, and how severe. For example, I bill for a squad that has a patient that is a "frequent flyer" who always calls 911 for a nosebleed to the ER, Medicare refuses to pay for those. Medicare's theory is that is still has to be medically necessary (unable to go by private vehicle) in order for them to pay for it.

so then what happens? does the agency have to just take it as a loss, should they keep billing the guy, knowing he is going to ignore the bill? Can they refuse transport because it's not "medically necessary"? what about calls such as a kid with a fever, who EMS will take in the ambulance, while the family follows behind, will insurance kick it back?

I know in NJ, we CAN'T refuse transport, EVER. if you have a hangnail, and want to go to the ER, the ambulance WILL take you.

It depends on who you are billing. Medicare considers the loading code to be "All Inclusive." But others like Auto Insurances will pay for the additional codes.

so do i need to put on the PCR that i used 4 pairs of gloves, linen, tape, 3 4x4s, tape, reusable straps vs triangular bandages? does it matter how much me get paid, or does it all fall under the whole "all inclusive?"

like the lady who calls all the time for help up from her chair,

can you charge insurance for lift assists, or just send a bill to the patients?

 

[RocketMedic]

Does a ticket have to be signed by the patient to be billable?

 

[BillingSpecialist]

Which insurances, or in what situations, will automatically pay for round trips (to appointments etc)? Versus requiring separately medical necessity statements each way?

I wouldn't suggest billing any of them without a medical necessity per trip. Usually the only insurances that will let you combined them on one claim & bill them is a Medicaid or Workers Comp, but even them are on a per insurance basis. It all depends on what each insurance wants.

 

[BillingSpecialist]

so then what happens? does the agency have to just take it as a loss, should they keep billing the guy, knowing he is going to ignore the bill? Can they refuse transport because it's not "medically necessary"? what about calls such as a kid with a fever, who EMS will take in the ambulance, while the family follows behind, will insurance kick it back?

I know in NJ, we CAN'T refuse transport, EVER. if you have a hangnail, and want to go to the ER, the ambulance WILL take you.

so do i need to put on the PCR that i used 4 pairs of gloves, linen, tape, 3 4x4s, tape, reusable straps vs triangular bandages? does it matter how much me get paid, or does it all fall under the whole "all inclusive?"can you charge insurance for lift assists, or just send a bill to the patients?

No you cannot "refuse" a transport for it not being medically necessary. If the patient calls, states it's an emergency & needs to go to the hospital, you can't refuse them. If it's a schedule transport, you could refuse that, you could even require them pay upfront before you transport them. If you bill the patient and they don't respond to the bill, or know they are just going to ignore the bill, the squad yes will more than likely have to take that as a loss. I would suggest still sending them onto a collection agancy, and maybe one day if they decide to be a responsible adult & attempt to buy a home or something they'll have to pay your first. It may never happen, but you aren't out anything by doing it.

With the child with the fever....it just depends on the documentation..how high was the fever, were there any other problems, does the pt have an extensive medical hx? The insurance may kick it back for "just a fever" you would have to bill it and see, alot of it depends on what kind of insurance they have too.

If you are going to bill for anything additional then yes, you need to document it. There is a code for BLS Disposable supplies, ALS Disposable supplies, that most of those thing would fall under, you can bill for pulse ox, ekg, iv, extra emt, defib, intubation. The insurance you are billing determines on whether you can bill the codes out or they are considered " all inclusive." Medicare will not take extra codes or most Medicaids, but most of your commercial insurances will, and definitely auto insurances.

Your lift assists can not be billed to the insurance, you would have to bill the patient's for those directly.

 

[BillingSpecialist]

Does a ticket have to be signed by the patient to be billable?

Yes, the patient should sign off on the billing authorization before you bill it out.

 

[Milla3P]

I know that routine transports require Medical Necessity (PCS) forms. But are these forms required for EVERY trip for a regular?

I was told a long time ago that a PCS is valid and applicable for a pt who is being transported for a regular routine reason (ie: dialysis) for 60 days.

Is that true, close to true or was I lied to for years?

 

[JPINFV]

I know that routine transports require Medical Necessity (PCS) forms. But are these forms required for EVERY trip for a regular?

I was told a long time ago that a PCS is valid and applicable for a pt who is being transported for a regular routine reason (ie: dialysis) for 60 days.

Is that true, close to true or was I lied to for years?

I don't remember the time limit, but yes. If it's something like dialysis 3 times a week (plus return), then they need one on file, not a new one every trip. If the dialysis patient, say, skips a session, ends up in the ED with fluid/electrolyte issues, and then is discharged, the discharge will need it's own PCS.

 

[Milla3P]

I don't remember the time limit, but yes. If it's something like dialysis 3 times a week (plus return), then they need one on file, not a new one every trip. If the dialysis patient, say, skips a session, ends up in the ED with fluid/electrolyte issues, and then is discharged, the discharge will need it's own PCS.

What about repeated ED discharges for identical Dx? (repeated falls) just something that I've run into recently.

 

[BillingSpecialist]

Yes, the medical necessity is good for 60 days for a routine trip, like dialysis or wound care or something like that. But for routine ER visits, discharges, no you can not use the same medical necessity the same way as you do for a schedule re-current trip. For every ER discharge, you will need a different medical necessity. And it is also correct that if you take that dialysis patient to the ER & then they are discharged, you can not use the dialysis medical necessity, you will have to get the dr to sign off on one that is different, specified for the discharge.

 

[Brandon O]

Yes, the medical necessity is good for 60 days for a routine trip, like dialysis or wound care or something like that. But for routine ER visits, discharges, no you can not use the same medical necessity the same way as you do for a schedule re-current trip. For every ER discharge, you will need a different medical necessity. And it is also correct that if you take that dialysis patient to the ER & then they are discharged, you can not use the dialysis medical necessity, you will have to get the dr to sign off on one that is different, specified for the discharge.

Why is this? I would presume that the question isn't whether the patient needs ambulance transport -- since that's already been vouched for -- but whether they need to go where they're going. But is there really doubt whether, for instance, a person needs to return home from the hospital?

 

[JPINFV]

Why is this? I would presume that the question isn't whether the patient needs ambulance transport -- since that's already been vouched for -- but whether they need to go where they're going. But is there really doubt whether, for instance, a person needs to return home from the hospital?

It makes sense superficially to say that this set of routine transports requires an ambulance, and that extra (return) trip isn't one of these routine transports.

Anything else, it makes about as much sense as the rule at my current hospital that says that OR scrubs have to be covered when outside the OR. After all, my raggedy [butt] white coat that lives in my trunk when I'm not at the hospital is apparently cleaner than the air in Southern California.

 

[Milla3P]

Is the 60 day renewal some sort of fraud protection proving that that particular person is still alive?

If its not that morbid, then why would a dialysis patient with CRF need to be reupped? Couldn't it be a more indefinite thing?

 

[Brandon O]

Is the 60 day renewal some sort of fraud protection proving that that particular person is still alive?

If its not that morbid, then why would a dialysis patient with CRF need to be reupped? Couldn't it be a more indefinite thing?

 

[WuLabsWuTecH]

Yes, I bill for several counties that are billing for the AMAs.

Why is billing for an AMA Treat and Release ridiculous?

Historically, in the areas I've worked we had never billed for AMAs. Now it is something that I heard has started within the last month.

So maybe i'm just not used to it. Multiple situations have come up where a Pt did not activate the 911 system and due to a technicality that Pt is now receiving a bill. Something I do not agree with. Also, I do not agree with a Pt's family receiving a bill if we work a cardiac arrest and leave their loved one on scene.

Also, some of the local Medics are wondering whether or not to have the Fire Department handle all AMAs/refusals then since it is still not in their policy to bill. The fire guys are going to hate doing all the paperwork though.

I'll be the first to admit that this is just how I feel personally about the issue and that I'm not used to this new idea of non-transports receiving bills from us since it had not been done in my area previously.

This is why we do not bill for responses. We roll up to a car accident that's a fender bender and neither party called us. Why should they pay for a service that they did not want? And actually, if we roll up to a car accident and there's no one that want's help, it's technically a no patient found, and no one needs to sign for anything...

Probably will see more and more of this. Reimbursement is tightening all around.


I can get behind this...


...but not this? Why would we not, outside of a misplaced sense of nobility? You think a physician doesn't bill for his time and expertise on an unsuccessful resus? The hospital writes off the supplies? A typical resus will use use a couple of hundred dollars in supplies and tie up an hr of truck time (say $100-200/hr operating cost). Why would you not seek reimbursement for that?


Sure, you can deliberately drive down your service's revenue stream...don't complain about money or equipment though.


It's a short-sighted view that many in EMS share unfortunately. At the moment medicine is a business in the US. EMS providers need to start realizing this.

We do not bill for unsuccessful cardiac arrests that we call on scene for our residents as a courtesy. It's our policy to write these off. We think it's a PR issue and that since we do not need the revenue of $50 (our residential billing rate)from that run to make our budget, there is no reason we can't, as human beings, decide to let that $50 go.

 

[WuLabsWuTecH]

Question for the OP on differential billing.

At my rural department, we have different rates for residents vs. non-residents. The terms are well defined (as someone who lives, works, or goes to school in the district). We bill $50 for residents and I think somewhere along the lines of $700 for non-residents. Additionally, we do not bill for runs into a specific township because that township contracts with our department, and they pay something like $1500 per run for each run we take in their township (so the agreement says we do not bill the patient). This has been going on for years.

But at my second department, we recently started talking about billing since the majority of our runs (60ish%) are now mutual aid into a city that bills our residents when they come mutual aid into our town. Because we have so few residents in our town and township, the majority of our runs are mutual aid. Someone mentioned that it would be illegal to bill differentially which is what is preventing us from starting billing. We would like to bill as our expenses are now at the point that we cannot sustain our annual budget on the levy alone, but we're only slightly over budget and don't want to bill the residents of the town (and our contract with the township that pays us $x per year says we can't bill them). The budget gap is such that billing mutual aid runs would more than make up for the gap, but someone said this is illegal? True? False? False but based in truth that was misinterpreted?