3 Definitions of Medical Necessity as Defined by Payers

A response from the following article


Ambulance reimbursement is unique in that insurance payout is not guaranteed based on providing service. Medical necessity must be proven through documentation in order for reimbursement. This can be both confusing and frustrating to EMS staff, because generally speaking, “medical necessity” is subjective.

There are typically three payer categories separated by their definition of “medical necessity”.



For these providers, a transport is deemed payable if a “prudent layperson might anticipate serious impairment to his or her health in an emergency situation.” In other words, would an average person consider the situation a medical emergency? Would the condition seem to warrant calling an ambulance rather than seeking alternative help?



Medicare is a federal government insurance provider that states they cover only ambulance transports in which no lesser alternative method of transportation could be used. This rather strict definition of medical necessity is reason for a majority of Medicare audits.



Medical necessity for government insurance provider, Medicaid, is defined at the state level. These requirements are more specific than Medicare’s federal definition and require quality documentation of conditions, interventions and procedures at the site.


In conclusion, payer requirements vary based on the insurance agency and their particular definition of medical necessity. It benefits all involved to understand various insurance payer standards. A good rule of thumb to receive full reimbursement is to make sure you provide a detailed report that describes your patient assessment, medical interventions and reason for transport. Play it safe. If it is not known to where you will submit the report, edge on the side of caution, abiding by the most stringent requirements. Be detailed on the reason ambulance transport was required and remember, good documentation is good patient care.


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 EMS for over 35 years in roles such as an EMT, EMT-I, M.I.C.T., Field Supervisor, Flight Paramedic, Cardiovascular Specialist, Assistant Director, and Director of EMS.
EMS Crisis Management Plan: How to be Tragedy Prepared

EMS Crisis Management Plan: How to be Tragedy Prepared

“It will never happen here.” That is what residents of the small close-knit community of Hesston, Kansas thought before the events of Feb, 25th 2016. But the unthinkable did happen. Armed gunman, Cecil Ford, stormed a local factory, killing 3 people and wounding 14.


You just never know what tragic events will occur in your community. Even in a quaint Kansas town with a population counting less than 4,000 people, citizens are not protected from these occurrences. As an EMS provider, we sometimes fall into a false sense of security and believe the tragic events that occur in other locations will not happen in our own communities.


EMS agencies must strive to develop those “what if” response plans for their staff. They should also work with law enforcement, community officials, and other emergency agencies to develop integrated response plans and implement joint training to be better prepared for mass violence or tragedy.


Response Plan points that need to be discussed within this meeting include:


  • Incident Command System
  • Communications plan
  • Role of medics (tactical team, swat team…)
  • Mutual aid plans


Getting all emergency leaders together seems to be challenging for some communities, however, there is great value in regular meetings. Besides providing the space to formulate and refine a Response Plan, these meetings enhance community professional relationships resulting in a more enriched and prepared community.


I wish to say thank you to all the emergency responders on the scene at Hesston, Kansas. There was excellent coordination and communication by all.


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.


Learning through Listening

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 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.


Addressing the OOPS of Documentation

Addressing the OOPS of Documentation


Everyone knows that good documentation should be a priority for EMS administrators, manager, and staff. But what should be done when performance doesn’t quite meet the standard?

The first plan of attack should be to handle the mistake with integrity. Own up to your mistakes and acknowledge them. Do not, for example, write that the “patient was unable to sign” on the signature line simply because you forgot to collect the appropriate signature or didn’t have the time.

Secondly, be proactive and confirm that a documentation policy is in place at your EMS department. An up-to-date documentation policy is imperative when considering the protection of a service’s employees, integrity, legality, and income. In the Medicare and Medicaid world, an action not documented is an action not taken. Recreating the events after they have taken place is a luxury you may not get or have the memory capacity to recall. Nobody wants to find themselves on a witness stand without a quality patient care report.

For this reason and others, EMS departments should establish a documentation policy stressing the importance of truthfulness and thoroughness. The policy should also contain guidance on legibility of all documents, what information should be included in the report, the amount of information contained within the report, and direction in obtaining appropriate signatures. This policy will guide staff in creating quality documentation- improving patient care, eliminating grounds of legal questioning, and increasing the chance of payment justification.

Documentation may not be the most exciting task in one’s day, but it may very well be the most important. Putting the time and diligence in creating quality documentation will be worth it, guaranteed.


Contact Omni EMS Billing if interested in participating in a documentation webinar lead by EMS billing expert, Grant Helferich.


Creating a Quality Assurance and Quality Improvement Plan

http://www.jems.com/articles/print/volume-40/issue-7/features/new-technologies-can-help-take-your-qa-qi-program-to-the-next-level.htmlPhoto courtesy Rob Lawrence/Richmond Ambulance Authority.

A response from the following article


By Grant Helferich

It is necessary that EMS agencies large or small have in place some form of Quality Assurance and Quality Improvement (QA/QI) programs within their agency. Whether this is a few members of the agency meeting to review policies, or an agency wide QA/QI program, noting places of possible improvement is necessary for a profitable and sustainable operation. Larger agencies may have the financial means to have sophisticated software to assist them in this process, but it is not required. Similar results can be accomplished with an investment of time.

The beginning step in this process is a complete review of your current policies–  from your dispatch policies to the completion of your patient care reports. It is important to review and update all policies on a regular basis. It is also important to make sure all your staff understands the importance of complete and accurate data. Correct reports assist you in making important decisions, and is considered mandatory if you want to sustain insurance fulfillment and avoid denials or audits. As Michael Gerber highlighted, “…everything is interconnected. Dispatch and operations impact clinical care, clinical documentation impacts reimbursement, reimbursement impacts operations and so on.” If there is a malfunction in any area, such as receiving reimbursement, consider outsourcing. It very well may be worth your time and pay for itself.

Learn more about the benefits of outsourcing here.

Contact us to get a free consultation about ICD-10 billing services here.

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.


New Technologies Can Help Take Your QA/QI Program to the Next Level

7/6/2015 by Michael Gerber and Rob Lawrence

Richmond, Va., Ambulance Authority (RAA) is well known for being a high-performance EMS system and for its community education efforts and implementation of a culture of safety.

But the agency has also recently taken a huge leap forward in the areas of quality assurance (QA) and quality improvement (QI). RAA, which serves as the sole provider of emergency ambulance services for the Virginia capital, has implemented a “Total Quality Management” (TQM) system. The system links quality management efforts in the clinical, operations and billing arenas in order to comprehensively improve RAA’s service and efficiency.

Each month, RAA’s TQM committee meets to discuss any potential areas for improvement. The director of reimbursement might mention a specific documentation issue that’s causing delays in billing or collections. The chief clinical officer may discuss intubation rates and educational programs being implemented to improve them.

The idea behind TQM is that everything is interconnected. Dispatch and operations impact clinical care, clinical documentation impacts reimbursement, reimbursement impacts operations, and so on. Like many agencies, RAA has a clinical services committee that focuses solely on clinical issues, where the medical director is joined by the clinical officer, the QA/QI coordinator, the training staff and other paramedics. But the TQM meeting adds another layer.

Attendees at the TQM meetings include the chief operating officer, the director of operations, the chief clinical officer, the quality manager, the director of reimbursement and the compliance director.

Believing that each aspect of agency performance is connected and part of the cycle of providing high-quality services, RAA uses its TQM approach to measure and analyze outcomes and processes and make adjustments to training and policies to achieve its desired outcomes.

Using Technology to Fill the Gaps
Previously, RAA’s clinical and documentation QI process focused on reviewing specific types of patient care reports (PCRs), such as all cardiac arrests; specific high-risk, low-frequency procedures (e.g., cricothyrotomy); and a certain percentage of other calls. The agency also would choose to review specific topics or themes during certain months—perhaps looking at reports written by new hires one month and field training officers the next. The billing team would then review the report to identify documentation issues related to reimbursement.

Like most departments, RAA used to perform these focused PCR reviews because, as a high-volume agency, trying to review every PCR provides a limited return on a significant investment of manpower and resources. Either several reviewers read the reports with little consistency or guidance on what to look for, or one person attempts to review every PCR but eventually gets so far behind he or she scrambles to catch up and can’t provide effective feedback to providers or correct documentation errors in time to impact billing. Practitioners may not receive the feedback until several weeks after the call, when they might not even remember the patient. RAA readers felt the process wasn’t as effective as it could be. They began searching for other solutions, and found one right in their own headquarters.

In the dispatch center, supervisors had already seen how technology could provide real-time feedback and lead to improvements. At any time, dispatchers can look at a monitor that shows whether they’re meeting certain performance standards. RAA uses FirstWatch, a California-based data and technology firm, as one method to monitor computer-aided dispatch (CAD) data and provide almost instant analysis.

In the dispatch center, that has helped drive improvements in areas like call processing times, where live feedback via the dispatch performance dashboard helps provide focus to the system status controllers on duty.

On the clinical side, RAA recently began using FirstPass, a tool developed by FirstWatch to automatically evaluate PCRs for adherence to protocols. FirstPass works by running each PCR through a series of tests based on certain criteria as soon as the data is available. The tests are based on treatment bundles and tailored to the agency’s protocols.

The software also compares each PCR to a universal protocol that checks reports for certain demographic and basic clinical data, such as baseline vital signs, signatures and other information RAA wants to collect for every patient.

Certain types of reports are screened further. For example, if the patient complaint is for chest pain or another cardiac-related problem, FirstPass will look for documentation of a 12-lead ECG. If none is documented, the incident is flagged. For chest pain patients, FirstPass will also look for appropriate documentation of specific treatments, such as aspirin or nitroglycerine administration.

FirstPass’s clinical care bundles are evidence-based but also tailored to RAA’s protocols and training. RAA is also working with the FirstPass team to develop even more sophisticated analysis and reporting tools.

The TQM Process
Now, when paramedic and RAA’s QA/QI Director of Operations Tom Ludin arrives each morning, he checks to see which reports were flagged by the FirstPass system. He can immediately review the PCR to determine if it was a documentation error, an omission in patient care or if there was a reasonable deviation from protocol. If the answer isn’t clear, he can talk to the crew who treated the patient first to help make his decision while the crew still recalls the details of the call.

“It gives a lot of opportunity to look through and see where improvements are needed,” says Ludin. “We can’t fix it if we don’t know it’s a problem.”

FirstPass not only allows for every PCR to be reviewed for minimal criteria, it also creates a system for measuring overall performance of the agency and individual providers. In many systems, simple database searches and spreadsheet computations can determine how often 12-lead ECGs are documented as having been performed on chest pain patients. But FirstPass creates an easy way to then track why that happened. On a continuous basis, supervisors can determine whether providers require re-education in clinical areas, documentation, or both.

“Ninety-nine percent of the calls pass the criteria. I never look at most of those,” says Ludin.

After Ludin reviews a PCR that failed a FirstPass test, he decides whether there was a deviation from protocol or a documentation error and emails the provider who wrote the report within one business day. That provider then has a chance to review the call and explain what happened, or correct the PCR, and Ludin and his colleagues determine whether any further action—such as remedial training—is required.

But while FirstPass allows RAA to check each PCR for certain criteria, it doesn’t replace having a real person dedicated to QA/QI. “FirstPass is a tool,” Ludin says, explaining that he still uses his own database queries and other methods for other aspects of the quality management process.

For example, Ludin reads a random selection of PCRs each month so he can look for any issues the computer might not catch. As an accredited dispatch center, RAA already reviews the 9-1-1 calls for critical cases and a random selection of other calls each month—Ludin uses the same list to determine which PCRs he will review.

Having a TQM system means that when issues are discovered by one department, the entire agency helps find a solution. This will become even more critical for EMS agencies when the next revision of the International Statistical Classification of Diseases and Related Health Problems (ICD-10) is adopted by payers later this year.

With ICD-10, the number of billing codes will greatly expand, and the importance of good documentation will increase. Having a TQM program is helping RAA prepare for these changes by bringing billing and clinical services to the table together. When the billers find an issue with documentation, they can ask the clinical supervisors about it and determine if it’s a documentation error or a misunderstanding by the billers over what service was actually provided. If systemic problems are discovered, the clinical department can conduct training or change the minimum required information to complete a PCR.

Closing the QI Loop
RAA keeps its quality management as nonpunitive as possible, focusing instead on finding ways to motivate its staff to make corrections and solve problems. Just publicly displaying some performance measures, either at the individual level or system-wide level, has led to improvements. Clinical lapses aren’t necessarily tied to performance evaluations, unless supervisors feel there are no efforts made to improve.

“You’re not evaluated on your QA/QI results,” Ludin says. “Instead it’s your responsiveness to training.”

When it was recently discovered that intubation rates were slipping after an influx of newly qualified paramedics, RAA’s training coordinators instituted a system-wide effort to improve—even though they knew not every single paramedic had unsuccessful intubations. In the crew Login Room, they set up intubation manikins and equipment, as well as some literature and videos on airway management. At the beginning of each shift, every ALS provider took time to practice intubation before heading out on the ambulance to run calls.

After the recent intubation refresher stations, RAA’s training staff received positive feedback from the providers, including one paramedic who credited the training with helping make his first live intubation successful.

RAA was also an early EMS adopter of self-reporting. Several years ago, operational medical director Joseph Ornato, MD, signed off on a self-reporting protocol that encourages providers to come forward when they make an error or omission.

But this isn’t to say that RAA doesn’t let providers know they value high performance. Each year when employees submit preferences for which shifts they want to work, RAA ranks them using a combination of seniority and performance. With FirstPass now in effect, that might include compliance to clinical protocols and PCR documentation in the future.

The Future of QA/QI
Technology adds one more tool to the TQM process, allowing personnel to spend more time doing what they do best—analyzing the problems and finding solutions—instead of spending hours determining whether the right boxes were checked. Software can’t replace having dedicated providers and educators, but it can make the system more efficient and more robust, allowing agencies to focus on areas where improvement is necessary and ultimately provide better care for their patients.