JPINFV
Gadfly
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It effects whether you have a job.
Billing and 911
- Thread starter Alas
- Start date
It effects whether you have a job.
Do you have a sense of how often you actually get reimbursed that? I think the incredible disconnection of field providers from our funding structure affects the care we provide... and not just in EMS-- all over medicine.
The uncertainty of the costs of the services we are providing to our patients is like administering a medication without being able to tell your patient any of the possible side effects, "it's not part of my job, you'll find out later." Isn't transport a form of therapy? Why can't we think about it in terms of indications, contraindications, side effects, etc?
In order to relieve the burdens on emergency departments, we need to start thinking about providing more care in the field and releasing patients-- or providing referrals and resources that don't incur the most expensive care in the hospital. We need to start moving away from transport being the only treatment modality we know. If we aren't comfortable counseling our patients on the financial ramifications of non-transport, how are we going to be ready to discuss the medical ramifications?
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The uncertainty of the costs of the services we are providing to our patients is like administering a medication without being able to tell your patient any of the possible side effects, "it's not part of my job, you'll find out later." Isn't transport a form of therapy? Why can't we think about it in terms of indications, contraindications, side effects, etc?
In order to relieve the burdens on emergency departments, we need to start thinking about providing more care in the field and releasing patients-- or providing referrals and resources that don't incur the most expensive care in the hospital. We need to start moving away from transport being the only treatment modality we know. If we aren't comfortable counseling our patients on the financial ramifications of non-transport, how are we going to be ready to discuss the medical ramifications?
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Perhaps, but billing can and will affect your job status (like JP said), your pay scale, COLA's, the condition of your equipment, availability of supplies, staffing and deployment, whether or not your service will be willing to buy and train on the most cutting edge equipment. Some places only compensate for six holidays a year, maybe 4-6 sick days, and have no 401k. How many privates are still starting basics at $9-$10/hr? Those pay rates were in effect back in 2002 when I started, and haven't changed in many places. How many third service agencies are still starting basics at 25k/yr give or take? You're better off collecting welfare and getting Section 8 housing, unless you're still sponging off of your parents.
There are still services out there that don't have CPAP, only a handheld suction device, the old two man stretcher (forget about the power Stryker), LP10's, etc. Do you work in a vanbulance? I wonder why (hint - $$$)?
Ever wonder why you're running for nearly all of your shift? Your agency staffs and deploys at the bare minimum. what would happen during a significant event or even just a call volume surge? Ever wonder why you're held over frequently? It's because they're not spending the money to hire and train, and attract applicants. People also tend to quit and leave staffing holes in their wake when their pay is too low.
Billing isn't going to affect our pt care. However, if you treat billing with such a cavalier attitude, it can and will affect the items listed above.
The difference between EMS and other medical professions is that we bill by level of service and then mileage. It's archaic. The problem with getting reimbursed for pt refusals would be solved by EMS going to billing by skill hours.
Agreed, but what about the case where it was a third party caller? Even if the pt wanted nothing to do with EMS initaially, we do tend to talk patients into agreeing to a battery of diagnostics, and often needless transports with invasive therapies that change nothing regarding the pt's outcome.
I agree with the sentiment, and I think paramedic practice could easily move to an RVU type billing system...but how would you put that type of system in place for BLS providers?
Another truth. Also why after my service started billing for refusals I started asking "did you call for an ambulance?" If the answer was no, "do you feel like you need an ambulance?"
If they answer no to both of these they are not a patient, it is documented that no assessment was done, and no bill is received.
The more that people are required to have some skin in the game, by having to provide payment, the more thought and research they'll put into whether a 911 call is appropriate for their perceived condition. I have to pay $15 for an Urgent Care visit, and $35 for an ED visit. as such, I'm not going to go for every little sniffle, headache, and papercut.
If they know they're on the hook for any 911 contact, they'll exercise greater discretion in calling us. Resuiring a co-pay with Medicaid coverage would be a good start.
In my county, we only do third party billing for county residents. No one that lives in the county ever pays out of pocket for EMS. If they starting charging co-pays per the pt's insurance, thensome of our patients would do things such as first call their pharmacist, the ED, their PCP, attempt to self medicate before calling 911.
Example: "I (or my child) has been running a fever."
"For how long?"
"Two hours or so."
"What have you taken for the fever?"
"Nothing (puzzled look) - I called you."
In some areas, fire suppression is looking to charge a fee for responding to certain incidents such as an MVA, a cut job, recurrent/malfunctioning alarm bells, as well as subscription fees for protection if your house catches on fire. This is quite controversial, but it this is going on.
If they know they're on the hook for any 911 contact, they'll exercise greater discretion in calling us. Resuiring a co-pay with Medicaid coverage would be a good start.
In my county, we only do third party billing for county residents. No one that lives in the county ever pays out of pocket for EMS. If they starting charging co-pays per the pt's insurance, thensome of our patients would do things such as first call their pharmacist, the ED, their PCP, attempt to self medicate before calling 911.
Example: "I (or my child) has been running a fever."
"For how long?"
"Two hours or so."
"What have you taken for the fever?"
"Nothing (puzzled look) - I called you."
In some areas, fire suppression is looking to charge a fee for responding to certain incidents such as an MVA, a cut job, recurrent/malfunctioning alarm bells, as well as subscription fees for protection if your house catches on fire. This is quite controversial, but it this is going on.
Ok what was the complaint? The guy walked down stairs, walked into the truck, where is the justification for a BGL and a four lead heart monitor.
I believe we should be reimbursed for services rendered but we really need to justify our practice, a guy stubs his toe and he gets charged for an ALS assessment, IV, monitor and pain meds.
Its ridiculous.
I believe we should be reimbursed for services rendered but we really need to justify our practice, a guy stubs his toe and he gets charged for an ALS assessment, IV, monitor and pain meds.
Its ridiculous.
You can't. Another talking point for advocates of the paramedic as the minimum cert lavel in EMS. I'd be willing to wager that the increased revenue from this type of billing would take care of the increased costs of having an all ALS workforce.
That's a good way to put it. don't forget to document that the individual (I'm always careful not to call them a patient) demonstrated adequate decisional capacity.
I'm told we bill basically 5 different codes. BLS, ALS1, and ALS2. We can bill for a small number of therapies like EKG and intubation, and then we bill for mileage (rounded to the nearest tenth of a mile). We do not bill a la carte for medications, or consumable items. I think our top ALS2 rate is about $1,200 (example would be cardiac arrest).
Then there is the issue of "payer mix". We are reimbursed differently for Medicare (80%), Private third party insurance (100%), and Mass Health (20%). Mass health is Massachusetts "Obamacare".
On average including all of our refusals, BLS calls, and various ALS calls we are reimbursed about $620 every time we go on a call.
We try hard to keep our refusal rate down. Yes, there are definitely cases with low risk repeat refusers (lots of hypoglycemia, lots of lift assists) and we don't push them hard. But we have all of our medics work hard even in pretty minor MVCs to transport them. I'm not talking about a 5MPH parking lot tap, I'm talking about a 25-30 MPH road crossing t-bone where everyone says "I feel fine". I think it really is good patient care to say "you should get checked out".
I agree with 46Young, billing does affect what your service is able to provide. Our small town of 18k people has two nearly brand new ambulances, new LP15's, new Lucas thumpers, CPAP, etc all thanks to our aggressive billing.
Then there is the issue of "payer mix". We are reimbursed differently for Medicare (80%), Private third party insurance (100%), and Mass Health (20%). Mass health is Massachusetts "Obamacare".
On average including all of our refusals, BLS calls, and various ALS calls we are reimbursed about $620 every time we go on a call.
We try hard to keep our refusal rate down. Yes, there are definitely cases with low risk repeat refusers (lots of hypoglycemia, lots of lift assists) and we don't push them hard. But we have all of our medics work hard even in pretty minor MVCs to transport them. I'm not talking about a 5MPH parking lot tap, I'm talking about a 25-30 MPH road crossing t-bone where everyone says "I feel fine". I think it really is good patient care to say "you should get checked out".
I agree with 46Young, billing does affect what your service is able to provide. Our small town of 18k people has two nearly brand new ambulances, new LP15's, new Lucas thumpers, CPAP, etc all thanks to our aggressive billing.
If I understand you correctly, anyone covered under Obamacare will be billed at only 20% of the private insurance rate? We're all screwed, doctors will go out of business, and private/not for profit hospitals will fall like dominoes.
Horse puckey. Bull caca.
Injuries come with physiologic signs and symptoms. If they are free of these, then they are probably not injured.
"Getting checked out" sticks your patient with needless bills, clogs up
EDs with inappropriate patients and often exposes patients to unneeded procedures that have a real risk of harm such as spineboarding, radiation from CTs, ect.
It does look good for your services bottom line and liability though, which is why I'm sure it's pushed so hard.
When I replied above I almost put a statement to the effect "disagreements and flamewar in 3...2...1...."
So you're telling me you've never had a patient from an MVC that says they're fine but you believe, from your evaluation, intuition, and experience that they really should be checked? Because I'm a complete novice and I have seen a refusal from an MVC that had a fractured cervical vertebra.
Nah, you're right, she should have walked it off.
True. That's where we are as a profession at the moment. There's not enough education to allow provider initiated refusals. Even if there was, we'll still be litigation phobic. I'm always going to put it back on the pt. I'm not going to be that one in 100,000 that loses their card or gets sued because the pt goes home and dies or something.
We will try to allude to the fact that our services and transport will not make any difference whatsoever in their condition and outcome. Flu like symptoms in the otherwise healthy 21 y/o, baby with a fever where the parents neglected to medicate w/ motrin or whatever, a sprained ankle literally right next to their car in the driveway and multiple family members onscene, a rash w/ no other findings, etc. would all be examples.
We always start with "We're always going to recommend transport to the hospital no matter what your condition is; we're required to by our department." "Now having said that...."
Not flaming, just disagreement.
Again, physiologic signs and symptoms. If they say "I'm fine but my neck hurts a little" than they're not really saying I'm fine are they? Signs and symptoms of injury warrant assessment. But the guy who says "no I'm not hurt at all" doesn't need transport to be "checked out" to satisfy an agencies billing and liability concerns, no matter how bad something appeared.
So your telling me she was not impaired and when asked stated NOTHING was wrong? Not even a little neck pain or stiffness? If so it should be written up as a documented case of occult spinal injury, perhaps the first one.
I'll bet she was walking with a rigid collar on the next day...
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At one point though does such aggressive billing place undue stress on the healthcare system? If someone does not want to go to the hospital, why burden the system as whole needlessly? Why put the unneeded financial stress of an ER bill on a family? I find this to be breach of the patients's trust, we are in a position of some degree of influence over our patients, and this abusing that relationship. Many of our patients call an ambulance because they are unsure about their health state, and are looking for an educated opinion. If we say "go to the hospital," many people are going to listen to us because part of our job is to decide if someone needs further care. If you know someone doesn't need the services that a hospital provides, don't take them there.
I understand completely that billing is what pays my wage and gives my a nice new shiny truck, but I am not going to transport someone that I know doesn't need it just because the patient doesn't know any better, which results in my company making money. I'd rather we not get the bill for transport than screwing a family, the receiving hospital, and the healthcare system as a whole.
Sent from my out of area communications device.
JPINFV
Gadfly
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Devils advocate time (even if it should be it's own subject), how much time is spent in paramedic school determining who needs to be hospitalized and who doesn't? Needing to go to the hospital and needing to go to the hospital via ambulance should be two different topics entirely. However, often a "you need to see a doctor, but don't need an ambulance" is often going to be interpreted as "you don't need a doctor."
I agree that patients shouldn't be forced to go to the hospital just for the ability to bill. However...
1. Refusing to force transport is not the same as providers more often being willfully ignorant of what, how much, and when bills are sent (and yes, I spent the majority of my time being willfully ignorant).
2. Ambulance services should bill for services provided. Treat and release is a service. Assessment is a service. Unless the patient says, "No, I'm fine, I didn't call an ambulance," then a billable service has been completed.