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Pro Bono: How Providers Can Help Reduce the Impact of Medicare Payment Cuts

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The American Taxpayer Relief Act of 2012 has hit all healthcare providers in the pocketbook pretty hard with the 2% across-the-board “sequestration” cuts in Medicare payments. For EMS, the 2% reduction in payments for ambulance service applies to all claims with dates of service after April 1, 2013. Operational changes are happening as a result of these payment cuts. Some ambulance services are looking to “retool” and streamline operations to become more efficient. In some cases, spending for new equipment is being placed on hold and pay increases for EMS staff are being deferred.

Although a 2% payment reduction may not seem like a lot of money, most ambulance services operate on relatively thin profit margins and very often the “payer mix” of those who pay the ambulance bills usually finds Medicare as the largest payer of ambulance service. And on top of this bad news, Medicare has increased its auditing of all healthcare claims, including ambulance claims. Medicare is more frequently denying payment where the patient care documentation does not support medical necessity for the ambulance service, where patient loaded miles aren’t accurately documented, or there's no patient signature authorizing the ambulance service to submit the claim for payment in the first place.

The bottom line: Your patient care report (PCR) is critically important when it comes to your ambulance service getting reimbursed properly for the services you provide. Clear, accurate and complete documentation can minimize the negative impact of the 2% sequestration cuts. Incomplete or sloppy PCR documentation leads to denied claims for payment or claims that can’t be submitted in the first place because the documentation is so poor. Now more than ever, we cannot afford inadequate PCR documentation.

EMS field providers play a critical role in the financial aspect of the EMS operation. The adequacy and accuracy of your PCR affects everyone—including field providers. When legitimate reimbursement dollars are left on the table because the documentation is not sufficient to support the claim for ambulance service, the entire organization suffers because it may not be able to afford new equipment or fund planned pay increases.

Field provider documentation can make a huge difference in the finances of your EMS agency.  Here are some tips for “tuning up” your PCR documentation:

Take Responsibility. Too often we hear field providers say they “didn’t get into EMS to do paperwork” or that the PCR is secondary to the actual patient care. That is a cop out. It ignores the reality that good patient care documentation is an essential part of providing health care. Accurate, honest and complete documentation of the patient’s condition and the treatment you provide is a critical aspect of providing EMS and the professional responsibility of every EMT and paramedic.

“Paint a Clear Picture.” Your PCR documentation must be accurate, complete and honest, and it should paint a clear picture of the patient’s condition. It should allow the reader to visualize the patient just as you saw the patient on the scene. Medicare’s standard for medical necessity for an ambulance comes down to this: Medicare will only pay for ambulance service when other means of transport are contraindicated. Your PCR documentation must address the issues that relate to this standard. Why does the patient need to go by ambulance now? When reading the documentation, is it clear why the patient cannot be safely transported by wheelchair van, car or taxi? In what position was the patient found, and how was the patient moved to the stretcher? What is the patient complaining of now, and what does the physical assessment reveal? What treatment was provided, and what was the response to this treatment? These are just a few of the questions that relate to “medical necessity” that your PCR documentation should address. Clearly, not all ambulance transports will meet the Medicare medical necessity rules, but your documentation must be complete, accurate and honest so that those who must decide whether the claim is billable will have all the objective information they need to make that decision.

Obtain the Patient’s Signature. Medicare and other payers require that the patient sign an authorization form that allows your agency to submit the claim for payment. Without this authorization, in most cases the claim cannot be submitted to Medicare, and then the billing staff must put the claim on hold to try to chase down the patient to get it. This delays payment and costs your agency valuable time. Most patients are capable of signing the simple “assignment of benefits” form while in the back of your ambulance. And if the patient is mentally or physically incapable of signing, then there is a host of other authorized representatives who can sign on behalf of the patient. The bottom line is that getting a patient signature is extremely important to the entire billing process—the ability of your agency to get paid for the service you provide may hinge on the effort you make to get this signature.

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