EMS Insider, Expert Advice

From Call to Claim

Each EMS agency has its 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 for 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 healthcare workers as professionals. Holistic 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 ever 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.

EMS billing cycle

Both EMTs and billers have difficult and stressful jobs. Here are a few suggestions for EMS managers to 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 reduce stress, but escalate 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 holistic patient care.
  5. Regularly evaluate your company’s processes and numbers. A top-to-bottom review, or as some term it, a SWOT analysis (strengths, weaknesses, opportunities and threats), must be comprehensive and include all elements of the agency.