By Grant Helferich
The Office of Inspector General (OIG) for the Department of Health and Human Services released their report late last year entitled, “Inappropriate Payments and Questionable Billing for Medicare Part B Ambulance Transports.”
This report, being 36 pages in length, reviewed 7.3 million ambulance transports from 15,164 ambulance suppliers (institutional based ambulance providers not included). Patient care reports from the first six months of 2012, January 1st – June 30th, were reviewed.
The Office of Inspector General’s (OIG) office reviewed these areas of ambulance transports:
- Transport destinations
- Transport levels
- Distance of urban transports
- Geographic locations where the beneficiaries who received transport resided.
- Other Medicare services that beneficiaries received
The report identified that for the first half of 2012, Center for Medicare and Medicare Services (CMS) paid $24 million for ambulance transports not meeting sufficient payment justification, including issues with medical necessity and transportation to non-covered facilities. The report also indicated that one in five ambulance suppliers had questionable billing practices.
One of the findings within this report indicated that the questionable billing was geographically situated within four metropolitan areas. These identified areas include Philadelphia, Los Angeles, New York, and Houston. These four metropolitan areas with the most questionable transports accounted for over ½ of the $207 million in Medicare payments questionable transports.
ESRD (Dialysis) transports remain under strong review from Medicare. Between 2002 to 2011, ESRD transports have increased 269 percent. The report even cited that “one Medicare Administrative Contractor (MAC) estimated that only 10 percent of beneficiaries with ESRD who receive hemodialysis-one of the two main types of dialysis require ambulance transports to and from hemodialysis treatment.”
Medical Necessity of the ambulance transport is a major issue as discussed within the report. It is cited within the Social Security Act that Medicare should honor “ambulance service where the use of other methods of transportation is contraindicated by the individuals condition, but only to the extent provided in regulations” -Social Security Act Section 1861 (S) (7)
Documentation is very important to justify why the patient could not be transported safely by any other means. Every patient must have a detailed assessment completed at the scene and those findings must be clearly documented within the patient care report. The information can be obtained from the patient, family members or a by-stander. The documentation must also support the level of services that were provided to the patient. As a rule, if the ambulance service is not medically necessary, the ambulance supplier should consider not billing Medicare for the claim, and billing the beneficiary directly for the services provided. This saves time, steadies revenue flow, and decreases the threat of delayed payments or audits.
The OIG also found that CMS paid $30 million for possible inappropriate ambulance transports in which the patient did not receive Medicare services at their destination. Patients are being transported to mental treatment facilities and physician offices, not a covered Medicare service locations.
The OIG has made five recommendations to ensure the correct usage of an ambulance transport. These recommendations include:
Determine whether a temporary moratorium on ambulance supplier enrollment in additional geographic areas is warranted
Require ambulance suppliers to include the National Provider Identifier for the certifying physician on transport claims that require certification
Increase monitoring of ambulance billing
Determine the appropriateness of claims billed by ambulance suppliers identified in the report and take appropriate actions
Implement new claims processing edits or improve existing edits to prevent inappropriate payments for ambulance transports
It is up to the ambulance service suppliers to take the time to review the patient care reports and vouch for their completion, quality, and overall necessity. As a general practice, ambulance suppliers should continue to review all of their internal processes including patient care, compliance, and documentation. This review process should include the implementation of a Quality Assurance / Quality Improvement program that involves all aspects of patient care to assure appropriate compliance.
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By Grant Helferich
A response from the following article:
I personally feel that we may be losing a valuable skill within the EMS community- the art of communication.
As a medic, it can easy to focus on all the new equipment and technology now at our fingertips. However, let this not distract us to the extent that we can no longer stop and listen to what people are saying around us, including the patient. There has been a saying in the EMS community for years that reads, “treat the patient not your monitor”.
There is so much we can learn, especially on those routine transfers, by just sitting and listening to our patients. I’m not talking about extracting clinical information but in learning life lessons. Stories about war time, love, stupid mistakes, people met… people are the experiences they’ve had. It will do one good to listen and learn from them.
It must also be said that gathering information for your patient care report is also a good use of transportation time. Demographic information, patient medical history, a recounting of the injury… these will all be useful and even imperative to know. By engaging in the art of communication, we can learn where the patient lives, their phone number and even their social security number for use in the report. This skill should be practiced rather than requesting the information from the Emergency Room.
When the patient is in distress or pain, talking to them will serve as a useful distraction, relieving stress and creating a more normalized environment. Try asking a few basic questions first, then follow those up with questions that require increased amounts of thought or recall.
We have so many innovations within our reach now in the back of the ambulance. It can be easy for us to become so distracted with our heart monitors, pulse oximetry units, and blood pressure monitors that we forget to actually look at the patient and see how the patient is responding to our care or treatments. Unfortunately, some technicians are also so distracted with their cell phones that they forget to check on their patient. This bending of the rules can grave impact.
In conclusion, aggressive care is sometimes appropriate, but in many cases, learning through listening can provide all the care a patient may need. Be safe and good listening.
Grant Helferich from Omni EMS Billing and Jason White from Marcer met with Senator Laura Kelly last Wednesday. Senator Kelly is a member of the Robert G. Bethell Joint Committee on Home and Community Based Services and KanCare oversight at the capital building in Topeka, Kansas. Helferich and White met with Senator Kelly to discuss EMS issues with current Medicaid reimbursements.
Hospital and physician groups have previously visited with the KanCare oversight committee to discuss similar issues they are facing with delayed or denied payments for their services. EMS has not been previously requested to attend these meetings, but will now be invited thanks to Helferich and White.
The meeting with Senator Kelly, included discussing the topic of Kansas Department of Health and Environment’s (KDHE) policy of reimbursing medical payments at 65-70% of Medicare allowable. EMS reimbursements by the managed care providers are far below this policy. Senator Kelly stated she will get a copy of this policy and share the information.
In concluding the meeting, Senator Kelly requested the participation of Kansas EMS providers in an upcoming survey distributed by the Kansas EMS Association (KEMSA). The KanCare oversight committee will be very interested in the results of this survey and asked that Helferich and White present the findings.
photo courtesy of YouTube
As professionals we pride ourselves on providing the best prehospital care to those entrusting us with their lives. We have spent countless hours in the classroom, riding on ambulances, and taking tests in order to become certified in our profession. In many states, paramedics are required to receive an associate’s degree to be eligible to take the certification exam. However, despite all of this training, many seem to have lost or forgotten the essential elements of documentation 101.
The following are 6 check-listed questions you should ask yourself before submitting your patient care report:
- Are your descriptions detailed enough?
- Are the abbreviations you used appropriate and professional?
- Is your PRC free of grammar and spelling errors?
- Is the Chief Complaint correct?
- Is your Impression specific enough?
- Are all other details in order?
1. Check your descriptions
Upon the completion of every ambulance call, a patient care report (PCR) must be generated to document all events that occurred. This includes a detailed assessment of the situation and a full recounting of the treatment administered to the patient. It is both specific and informative; free of ambiguity and negligence. But yet, after all of our extensive training, the best we can do in our detailed assessment is “patient has pain to the arm”?
– Which arm is the patient having pain in?
– Is it the upper or lower part of the arm?
– What was the timeline of the incident?
– What was your assessment when you palpated the arm?
– Were there distal pulses during your assessment?
There are many fine details that should be documented in your PCR. “Patient has pain to the arm” will simply not do. For this reason, a documentation policy should be in place (Read more about documentation policies here).
2. Review abbreviations
There has been a steady degradation of the communication skills in the United States, especially with the introduction of instant digital communication. They have reduced the English language to gibberish. This language should not have a place in a PCR.
Adding to this communication degeneration is the misuse of medical abbreviations in PCRs. Abbreviations should be avoided in a professional report due to easy confusion in a court of law or by insurance providers.
Some examples of abbreviations that should never be used include:
P.U.T.S. Patient unable to sign.
T.M.B. Too many birthdays.
F.L.B’s. Those funny looking beats in an ECG.
HTK. Higher than a kite.
3. Check (and recheck) spelling and grammar
Your PCR should paint a picture, but this is impossible to do without proper English. Besides not being accurate or professional, incorrect English may very well lead a reader to believe something false. For example, there may be confusion (and laughter) if a report was to say “patient fainted and her eyes rolled around the room”. This is a humorous example, but dire consequence can follow confusing reporting.
Reporting should be free of misspellings and the understanding of what you are trying to say should be clear to the reader. The trauma surgeon should have a good understanding of the mechanism of injury that brought the patient to his emergency room upon skimming your report.
4. Assess your chief complaint
An area of the PCR that is frequently misused is the chief complaint. The chief complaint should explain why you were called to the scene or why the patient is being treated. It is not the cause of the injury. For example, a chief complaint is pain to the right lower arm, not the fact the patient has fallen off a ladder. It should be noted that using the patient’s own words is an appropriate practice if they describe symptoms of the chief complaint.
5. Review your impressions
An impression encompasses what the patient treatment is for. “Trauma” and “fall” are too vague to be used here. Body areas or symptoms that are being treating should be included. In other words, what treatment protocol is being followed? If you are following your head injury protocol, and your assessment indicates a possible head injury, this should be included in your impression. Multi-systems trauma scenarios bring additional challenges, but if multi-body systems are involved, they all should be included in your impression.
6. Check the final details
With the implementation of a more detailed ICD-10 coding, the patient’s past medical history and medications are important to note. Avoid using the statement “history on file”. Document their history completely. Hospital providers use this information if the history could affect the patient’s outcome. A patient may have a longer recovery time due to their past medical history.
Another important aspect to clearly document is the outcome of your treatments. Some PCRs have a standard text box that indicates “improved”, but in your narrative you should clearly document how the treatment improved the patient’s condition.
Detailed documentation plays a role in ambulance transport reimbursement. If your organization has been plagued with poorly written PCRs, you could be in poor financial health. This is especially important with the implementation of ICD-10 coding. Make sure you take the time to check the pulse of your organization’s documentations skills and provide the necessary education for your staff.
Grant Helferich holds various seminars, helping EMS professionals and billing staff with their documentation questions. Contact him to register you and/or your team for his next webinar.