Facing rising costs and shrinking budgets, EMS systems are seeking to maximize revenues by maximizing collections, including billing insurersƒand in some cases, familiesƒfor responding to calls involving deceased patients.
EMS attorney Doug Wolfberg notes that Medicare "pays a limited benefit when an ambulance is dispatched for a deceased beneficiary. What [it pays] depends upon the time of legal pronouncement of death."
According to Medicare rules, if the patient is declared dead "by an individual authorized by the state to make such pronouncements" after dispatch but before the beneficiary is loaded on the ambulance, Medicare pays the base BLS emergency rate (without mileage or rural adjustment) even if an EMS crew provides no treatment. After pickup and prior to or upon arrival at the receiving facility, Medicare pays for the "medically necessary level of service furnished."
EMS systems employ various strategies
The Lee County, Fla., EMS system, which includes 17 fire districts and three municipal services, began billing for deceased patients in 2005, said David Kainrad, program manager for administration and finance for Lee County Division of Public Safety. However, the county bills only if EMS personnel actually ˙workÓ a patient who dies or who can't be resuscitated.
Lee County bills both Medicare and private insurance, but doesn't balance bill the family. "We don't bill those who don't have insurance or if we don't have the information," Kainrad said. "We remain sensitive to the families."
During the past three years, the county has billed $776,906 for 1,957 deceased patients and collected $264,404. "That's significant money; that's about the cost of two large ambulances," he said. "We owe it to the taxpayers not to leave money on the table."
Metropolitan EMS in Little Rock, Ark., bills Medicare, private insurers and families when it responds to a deceased patient. "Our consultant said Ú we can't bill Medicare unless we bill everyone else," said MEMS Finance Director Larmon VanWinkle.
"Medics document on the patient care report that there was no transport on a DOA. If they get the name and age of the patient, we have a database that shows the [insurance] status for Arkansas residents," he said. "If we have insurance information, we bill everyone, even the self-pay."
MedStar, the public utility-model EMS system that serves Fort Worth, Texas, bills Medicare, third-party insurers and families. "We bill even if there's no treatment," said Cyndi Patchura, MedStar business operations supervisor. "We send a bill to the patient to see if there is insurance, and we bill the estate or the surviving spouse. We send it to collections if the patient has insurance, there's a balance due and the spouse doesn't pay it."
According to Patchura, MedStar medics get what information on the patient they can at the scene without questioning family members "because they are sensitive to the family and don't feel comfortable asking for information."
MedStar Director Jack Eads said he's "heard no complaints" since MedStar started such billing.
Idea provokes firestorm in Pinellas
Pinellas County (Fla.) Commissioners voted May 6 to allow Pinellas County EMS and Fire Administration to establish a rate for patients who die at the scene prior to transport. The move came in response to the county's EMS billing auditor_s opinion that, "At the minimum, you should bill where you worked on the patient but they died at the scene and were not transports. You are also entitled to bill these if you dispatched but did not work on the patient. If the concern is to spare the family further financial burden Ú send a letter to the family expressing sorrow for their loss and advise them you will accept assignment of insurance benefits as payment in full."
The auditor noted that Medicare pays at the BLS emergency rate if an ambulance is dispatched immediately to a scene where the patient is declared dead. The memo also suggests obtaining the deceased patient's name and other information from the morgue when necessary.
"We got the auditor's report in March, and it directed us to go get the money we leave on the table," said Chuck Kearns, who served as director of Pinellas County EMS and Fire Administration for 11 years before he resigned suddenly June 27.
According to Kearns, fire department first responders "will do nothing different" once the new policy takes effect. "They won't be asked to get anything more than the patient's name and address; we have electronic means to verify insurance online, and that will all be done in an office after the fact."
Nevertheless, the plan provoked outrage from some area fire chiefs. "To slap an additional bill for a service that's not rendered, although it may be legal, we_re not sure that it's right," Largo Fire Chief Mike Wallace said on a local TV news program.
"This is insensitive and puts us in a bad spot to ask a grieving family for billing information or search for that information," Clearwater Fire & Rescue Chief Jamie Geer told the EMS Insider. "I seriously doubt you'll ever see that policy developed."
But Dick Williams, director of Pinellas County_s emergency communications/9Ï1Ï1 department, who took Kearns_ place as director of EMS and fire June 30, said, "The county commission has approved this, it's authorized by Medicare; and if the ambulance has been dispatched and the patient is deceased we will bill. The fire service thinks this is insensitive, but we're working carefully to create a solid policy so we won't encroach on the grieving family."
The fire service has been lobbying to take over EMS transport in Pinellas County, which has a public utility-model EMS system that employs a private companyƒcurrently Paramedics Plusƒto transport patients. The fire departments currently provide ALS first response.