From Call to Claim


Each EMS agency has their own yardstick as to how they will measure corporate success. Some agencies may measure quality by their response times, others by medical intervention success rates, and still others by code blue save statistics. But shouldn’t quality care include the complete package- response time, care given, reports completed, and claims paid?

Let us consider this: you receive a call of assistance, dispatch gives you accurate information and address, you make it there in record time, get the patient stabilized and delivered to the hospital. Hospital staff recognizes you for saving the patient’s life. All is well…until the patient gets a hefty bill for the ambulance transport. Insurance has denied payment due to poor documentation in the patient care report.

After everything the EMS crew provided for the patient, they neglected to complete the process and deliver a detailed and accurate patient care report to the billing office. What part of this experience do you believe the family will be discussing with their friends? A large avoidable bill will mar the reputation of health care workers as professionals. Wholistic patient care, and thus true EMS success, begins at the emergency call and ends after the claim is settled.

It must be noted that EMS providers have a very difficult job. They find themselves in situations that very few people should have to experience. However, EMS billers also have a very stressful job. They are frequently expected to magically turn inadequate reports into paid claims. Billers deal with lack of needed information and are blamed when claims are not paid. They were not at the scene of emergency, and should thus not be expected to know information left out on the patient care report. Their job is also difficult in that they must work with hurt and confused family members who are faced with crippling bills because of denied claims.

Both EMTs and billers have difficult and stressful jobs. Here are a few suggestions for EMS managers that can help smooth operations from call to claim.

  1. Consider a ride-along program. Permit your billers to shadow your providers, allowing them to see first-hand what providers face on a daily basis. On the same token, the EMS providers should also spend some time working alongside the billers. Let the providers answer the questions about medical necessity or visit on the phone with the patient’s family about why the ambulance transport was denied by insurance.
  2. Take the time to review your current departmental policies. Make sure they provide the information your staff needs to be successful. Clear policies not only reduces stress, but escalates success long-term.
  3. Review your job descriptions. Make sure to clearly outline the responsibilities of each position within your organization. Make sure all positions are adequately covered and overlaps are intentional.
  4. Provide reoccurring training for your staff to be reminded why certain protocols are imperative for wholistic patient care.
  5. Regularly evaluate your company’s processes and numbers. A top to bottom review, or as some term it, a SWOT analysis, must be comprehensive and include all elements of the agency.
Grant Helferich is employed as the EMS Advisor/Client Trainer with Omni EMS Billing in Wichita, Kansas. He is a former member of the KEMSA Board and has also served as the treasurer and president of the KEMSA Administrator’s Society. He was certified as an EMT, EMT-I, M.I.C.T. , and T.O. II. Grant has worked as an EMT, EMT-I, M.I.C.T., Field Supervisor, Flight Paramedic, Cardiovascular Specialist, Assistant Director, and Director of EMS.

Special Report for WPS Ambulance Providers

On March 22, 2016, the Wisconsin Physicians Services (WPS) Learning Center conducted a “Ground Ambulance Level of Care Teleconference”. The meeting highlighted some issues and questions being asked within the Center for Medicare and Medicaid Services (CMS) and medical coding community.


One of the main topics discussed at the teleconference centered on a clarification issue.

A request was sent to CMS asking for further insight into the following question, “Is medical necessity to bill an ALS1 level of care (Advanced Life Support) established by treatment provided to the patient during transport or the patient’s reported condition at dispatch?” CMS responded, “The ‘apparent’ necessity for the reported condition at the time of dispatch determines if an ALS1 is payable.” (This is something I have been discussing with WPS for several years. I am glad to report a consensus has finally been reached on the matter.

To add further clarification to this, WPS stressed that 911 centers must have protocols in place to help determine whether an ALS or a BLS (Basic Life Support) unit should be dispatched based on the information received from the caller. Even if a center only has ALS units available, protocol must be established and followed.


Vague Terminology

Another point WPS spoke about at the teleconference was the use of vague terminology within documentation and reporting. Insufficient data automatically discredits the claim of medical necessity in the transport. General terms such as “injured”, “fall”, “pain”, or “swelling” should be explained within the patient care reports or not used at all. WPS and CMS are looking for detailed information. Did the patient trip on an object? Is the pain dull or stabbing? Spend more time in being descriptive in your reporting.


Medical Necessity

Documentation needWPS Piecharts to leave no doubt that ambulance transportation was needed and no other method could be used. WPS cited Comprehensive Error Rate Testing (CERT) pages in referencing the mistakes ambulance transports found during audits and reviews. In the 3rd quarter of 2015, ambulance transports made up 7.04% of all errors found in the submission of claims to WPS. Of these errored transports, 98.45% were documentation issues that did not support medical necessity. The rest were coding errors on the claim form.


Crew Member Signatures

WPS requires that any crew member that provides patient care while enroute to the receiving facility must sign the patient care report. Remember that signatures must be legible, or the name and credentials must be printed alongside the signature line.

WPS has scheduled an ambulance billing course on June 16th in Salina, Kansas. The course is free but pre-registration is advised as seating is limited. Go to the WPS Learning Center’s website to learn more and register.