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EMSA Review Finds Inefficiencies in Oklahoma

TULSA, Okla. -- Read the city's operational review of EMSA. Read past stories and view documents related to the Tulsa World's EMSA investigation. A city review of EMSA's operations has found a rudimentary system of verifying patient addresses, risky storage of patient credit card information, a high rate of cases turned over to the agency's law firm and inefficient practices throughout the organization. The review makes about 50 findings related to EMSA's practices and accompanying recommendations for improvement.

Overall, the review found "no systematic approach to continuous improvement" at EMSA. The review will be presented to EMSA's board at its monthly meeting Wednesday in Tulsa and Oklahoma City. The Emergency Medical Services Authority is a government agency that oversees a contractor to provide ambulance service to more than 1 million people in Tulsa, Oklahoma City and surrounding cities. The city's Management Review Office launched its review of EMSA in April, following a Tulsa World investigation. The agency had filed numerous lawsuits against participants in a city utility-fee program that is supposed to cover out-of-pocket costs for ambulance service.

It was also sending every patient a bill that did not indicate whether the patient participated in the city utility program. EMSA's board voted to request an audit, which is set to begin in mid-September, by the State Auditor and Inspector's Office. EMSA has since changed its billing practices and instituted other changes to improve communication with customers.

EMSA CEO Steve Williamson said the agency has taken action on about half of the city review's findings. "We gave the MRO (Management Review Office) full access to our business processes, and they provided some excellent constructive feedback that we plan to use to improve EMSA's services and processes in the future," Williamson said in an email to the Tulsa World. The review found that EMSA's procedures to collect address information from patients and verify them later were inefficient.

"Better address information must be collected by EMSA earlier in the process," the review states. EMSA uses data provided by the city's utility department to determine whether patients are enrolled in the utility program. However, the process identifies patients by address and does not use any unique identifier for patients, the report states. "There is a fundamental design issue within the MSP program (Medical Service Program) that creates difficulties," the review states. "That issue is the fact that there is no unique, personal identifier for MSP (utility) program participants. Addresses, not people, participate in the MSP but it is the people, obviously, who actually receive the service."

The review recommends creation of a unique identifier to better track patients in the program. It also recommends purchasing portable scanners so that paramedics can scan patients' driver's licenses in the field. EMSA should make better use of scanning technology to keep track of checks and other key documents, the report states. The agency currently uses a system from 2004.

"EMSA's new Ikon scanning system, which was purchased over a year ago and without substantial participation by IT, sits in the scanning room in Oklahoma City unused. As of late May, EMSA could not identify a plan to implement the new scanning system." EMSA and its contractor, Paramedics Plus, claimed that the agency collected information from patients via hospital "face sheets" in up to 70 percent of all cases. However, the review found a 20 percent collection rate in a sample of cases.

The review recommends that EMSA work out an arrangement with Tulsa hospitals to collect information on patients transported by ambulance. The review also made numerous findings related to handling of patient credit card information. "TotalCare applications from 2011 remained unscanned with unsecured credit card information. Prior applications are held in an unsecured cabinet within the scanning office."

The report found similar security gaps with credit card information collected by phone or from customers who walk into the office. The report also finds that EMSA turns a high number of cases over to its law firm, Works and Lentz, related to patients who are enrolled in the city utility program. "Many MSP participants are being sent to Works and Lentz for collections purposes. In August 2011, for example, 28 percent (330) of all of the Tulsa accounts passed to Works and Lentz (totaling 1,175) were MSP participants," the report says.

The review called that rate "a major public relations problem for EMSA." "When the apparent lack of public knowledge concerning the MSP requirement that insurance information must be provided by MSP members is combined with such a high percentage of MSP participant accounts being turned over to Works and Lentz, it is not surprising that the public issue emerged," the review states.

Other findings involve a lack of competitive bidding. Out of nine providers that involved EMSA expenditures of $50,000 or more, "at least six and possibly more were sole source agreements," the review states. "EMSA's CFO, Kent Torrence, indicates there has not, in the past, been consistent competitive bidding of services and commodities," it says. The review states that EMSA has 10 days to formally respond, and then the city and the agency will work together to implement the recommendations.

EMSA provided a list of 18 changes and improvements it has already made to its "back office" procedures as a result of the review. "As a top EMS leader in the nation, we look forward to any opportunities that allow us to refine our practices to best serve our customers and provide top-quality emergency health care," Williamson said. In a statement provided via email, Mayor Dewey Bartlett said, "This review provides a new perspective for board members to consider as they determine how to employ best practices to ensure the continued delivery of the highest quality of care under the constraints of fiscal responsibility and accountability."

Key findings
The city Management Review Office's review of EMSA's operations made about 50 findings and recommendations for improvement. Here are selected recommendations from the city's review: Improve communication with citizens regarding a city utility-fee program. Develop a system to track and make improvements in operations. Improve procurement practices. Improve use of data for the city utility program. Increase focus on revenue management. Enhance security. Improve nonfinancial key performance indicators.


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