Can upper management/billing force us to write an addendum?

[Christopher]

Provided that what is being asked is something that the provider has the appropriate training to document and isn't lying, does it matter? Furthermore, the company's financial incentive is my financial incentive. If the company doesn't make money, than it closes down and I subsequently don't make money.

These are stressors which play a large role in organizational failures. In a perfect world I should not be stressed about these things, but the reality is we probably do care whether or not we get good billing money. I do not see an issue with accurate documentation such that you get what you're "due".

I see an issue with pushing documentation from the financial side. If you harp on employees that if they don't document "the right care we won't get paid and you won't have a job," you're possibly introducing a stressor to over-document.

Let's say Company A's documentation class covers how to appropriately document patient care using the available tools without mentioning financial incentives for various options; Company B's documentation class focuses on how to document such that the company can bill so that folks can "keep their jobs". If each of these companies are charged with fraud, which one has the latent organizational factor involved?

Organizational safety cultural is very important (/me takes his nuclear hat off).

 

[Carlos Danger]

There is a fine line between "restating the critical points" to force an insurer to pay and retooling documentation to improve billing rates. One is clarification and one is fraud.

Of course documenting something that didn't happen is fraud.

I didn't realize that's what this discussion was about, though.

 

[Clipper1]

I see an issue with pushing documentation from the financial side. If you harp on employees that if they don't document "the right care we won't get paid and you won't have a job," you're possibly introducing a stressor to over-document.

Why should EMS be the exception? All other health care employees are informed, lectured and are conditioned now to have concerns over the financial side of health care. This even starts in their college programs. Most have seen cuts in staff due to the financial side. Yes, it might be a "stressor" to you but you might not be away that several in health care have lost their jobs due to layoffs if the financial side doesn't add up for them. Ask any other allied health care professional about their charting. Allied health services which may also include Paramedic, are reimbursement driven. In college they may even have a class on health care business models to learn about the financial side and reimbursement. Each allied health department in a hospital almost acts like an individual business. It is only as successful as the individuals who are in that department. Most allied health professionals have to document volumes of notes for just one short session of being with a patient to have the insurances (including Medicare) consider reimbursements. If the reimbursements don't come in, departments can be eliminated or stripped to bare bones. As any OT, PT, SLP, RRT or RT about this. RNs also must see documentation for signatures are done for almost every procedure by either the patient or the family although most of the time it is the physician's responsibility. If someone doesn't do the checks and balances to ensure everything is done properly, people do get in trouble and sometimes that might even be the patient if all the proper protocols are done even for the paperwork. When there is an inspection, JCAHO or what ever agency including CMS itself will track patient charting from beginning to end. If it is your (hospital employee) charting which is dinged, expect serious lecturing and it might go in your personnel folder or your charting will be looked at with a microscope for a long time. No union will protect any employee who fails at what is expected of them in this area. No even the nursing unions.

To succeed today in health care as a professional you must be able to look at the whole picture. It is a business and if the money does not continue to come in, not only are you affected but also the patients if you fail to do what is expected of you.

 

[JPINFV]

There is a fine line between "restating the critical points" to force an insurer to pay and retooling documentation to improve billing rates. One is clarification and one is fraud.

Provided no one is lying, how is it fraud?

 

[JPINFV]

These are stressors which play a large role in organizational failures. In a perfect world I should not be stressed about these things, but the reality is we probably do care whether or not we get good billing money. I do not see an issue with accurate documentation such that you get what you're "due".

...and see, in my profession what I bill will eventually be directly tied to what I take home. Additionally, there's something like 6 different types of billing levels for each encounter that is based, in very large part, about properly documenting my H&P. Is it fraud if I properly document my encounter in a manner that maximizes what I can bill for, which directly and ultimately affects how much money I make? Provided I'm not lying, the answer is no.

EMS, on the other hand, is shielded. It doesn't matter whether you run 5 BLS calls or 5 CCT calls, you're making the exact same money at the end of that day. The bigger question, however, is if you properly document your calls, would that lead to additional money coming into the system, which could lead to better pay, equipment, training, etc. However, because you're removed a few steps, it seems like you believe that documenting, in part, to maximize billing (again, provided no one is lying about what is done and what was seen) is somehow fraud. That's simply not true.

I see an issue with pushing documentation from the financial side. If you harp on employees that if they don't document "the right care we won't get paid and you won't have a job," you're possibly introducing a stressor to over-document.

Without lying, how can you over document?

Let's say Company A's documentation class covers how to appropriately document patient care using the available tools without mentioning financial incentives for various options; Company B's documentation class focuses on how to document such that the company can bill so that folks can "keep their jobs". If each of these companies are charged with fraud, which one has the latent organizational factor involved?

Um, if there's fraud actually occurring, both have issues. Real fraud doesn't occur by accident.

Organizational safety cultural is very important (/me takes his nuclear hat off).

This isn't a safety issue.

 

[Christopher]

...and see, in my profession what I bill will eventually be directly tied to what I take home. Additionally, there's something like 6 different types of billing levels for each encounter that is based, in very large part, about properly documenting my H&P. Is it fraud if I properly document my encounter in a manner that maximizes what I can bill for, which directly and ultimately affects how much money I make? Provided I'm not lying, the answer is no.

If you document the H&P you perform, you're not lying. If the H&P you perform entitles you to higher billing, so be it. This is not what I'm talking about.

EMS, on the other hand, is shielded. It doesn't matter whether you run 5 BLS calls or 5 CCT calls, you're making the exact same money at the end of that day. The bigger question, however, is if you properly document your calls, would that lead to additional money coming into the system, which could lead to better pay, equipment, training, etc. However, because you're removed a few steps, it seems like you believe that documenting, in part, to maximize billing (again, provided no one is lying about what is done and what was seen) is somehow fraud. That's simply not true.

No, pushing billing as the reason for documentation can be a latent organizational factor which can lead to fraud. This is different from billing for what you did. I stand by my claim that appropriate documentation of patient care is adequate to bill appropriately. If you cannot make the determination from the patient care report as to what (if any) billing is applicable...the PCR is probably not adequate w.r.t. patient care either.

Without lying, how can you over document?

ePCR's run into this problem via field defaults.

Um, if there's fraud actually occurring, both have issues. Real fraud doesn't occur by accident.

My point was if a fraud claim is investigated, one organization has a latent cultural factor, the other does not. CMS is cracking down on billing fraud, and these will play a role in a company's liability.

This isn't a safety issue.

I'm so used to saying that phrase, my inclusion of "safety" was unintentional. I don't actually see it as a safety concern.

 

[Carlos Danger]

No, pushing billing as the reason for documentation can be a latent organizational factor which can lead to fraud.

I can kind of see why you say this, but at the end of the day I don't see much risk of a slippery slope here. There seems to be little potential that the requirement of an addendum to restate true and already documented facts will eventually cause paramedics to document things that actually didn't happen, in the hopes that their employer can bill more.

From the sounds of it, the OP's employer didn't even explain to them what the addendum was for. It's not like they were saying "the more you document = the more we can bill = the more we can pay you, wink wink."

Early in my career I worked for several private companies that had requirements like this. Believe me, there was ZERO risk of over-documentation....many of us needed to have our arms twisted just to write the bare minimum. Like the OP, it was never even explained to us what the extra forms were for. We were basically just told "these forms are important for billing and you'll be fired if you don't fill them out".

I stand by my claim that appropriate documentation of patient care is adequate to bill appropriately. If you cannot make the determination from the patient care report as to what (if any) billing is applicable...the PCR is probably not adequate w.r.t. patient care either.

Unfortunately, this is where you are 100% wrong. You don't seem familiar with the ways that insurers make it intentionally difficult to file claims.

You can definitely document perfectly appropriately and still have the insurer reject the claim. Happens all the time, at all levels of healthcare, but is a huge problem for the small, private ambulance services that really rely on reimbursements, don't maintain an army of billers and lawyers, and live on a thin profit margin.

In addition to rejecting any claim that isn't 150% clear, the insurers also regularly reject claims that they KNOW are properly documented and legitimate claims, just because they know that a few of them won't be re-submitted and they'll save some money. The insurers know their contractual and legal limits and stop just short of violating them. It's kind of like when corporations knowingly break laws and regulations because the penalties that result from doing so cost a lot less than the money they save by breaking the rules. They just don't care about the affects of their actions on others. The ambulance companies have little recourse but to play the game.

If this weren't an actual problem, why do you think so many private companies require these types of addenda? It isn't just because they like extra paperwork.

 

[Christopher]

If this weren't an actual problem, why do you think so many private companies require these types of addenda? It isn't just because they like extra paperwork.

I base this on our collection, rejection, and repayment rates which are all great. We do nothing more than collect signatures appropriately and document patient care adequately (and perform rigorous QA/QI). Perhaps we just have a good ePCR setup with a good billing company. I'm trained to doubt we're more than one standard deviation from the mean.

Even the other service I work for is not nearly as nitpicky as folks make this out to be, and they're the most anal retentive service ever. They have crappy collection/rejection/repayment rates and they still don't harp on our documentation (yes, we do IFT too) as a means to keep our paychecks.

I've not disagreed that insurers will stick it to you. I've not disagreed that they'll not pay whatever they think they can get away with. I certainly won't disagree with the complaint that CMS is an absolute bear to deal with. I've risen no complaint w.r.t. the original answers to the OP ("yes, your employer can ask you to clarify a PCR for billing purposes.").

I'm cautioning against the attitude that it is Ok to push providers to document for better billing to "keep their jobs".

 

[JPINFV]

ePCR's run into this problem via field defaults.

How so? If the ePCR requires lung sounds, than what's the problem with that? Shouldn't the EMT be listening anyways?

As an aside, current health care reform is pushing for electronic medical records in hospitals. The unintended side effect is that electronic medical records makes it significantly easier to bill, especially bill at a higher level (medical visit billing is more based off of the H&P than on treatments provided. Procedures are billed separately than the visit). The end result is more billing at higher level for visits. Unfortunately for Medicare/Medicade, this isn't fraud, even if they're looking into it as a possibility.

My point was if a fraud claim is investigated, one organization has a latent cultural factor, the other does not. CMS is cracking down on billing fraud, and these will play a role in a company's liability.

CMS still has to prove fraud existed.