Administration and Leadership, Exclusives

Is Your Organization Leaving Money on the Table?

Across the U.S., unpaid emergency transport bills are costing counties millions of dollars each year. For example, in 2017, Commissioners in Palm Beach County, Florida, approved writing off $11.8 million in “uncollectable emergency transport patient accounts.”1 Similarly, the city of Berkeley, California, reported a five-year average of uncollected ambulance fees amounting to $2.6 million per year.2

Soft billing practices, lack of billing transparency and increasing out-of-pocket expenses as a result of high deductible plans have all contributed to the growing debt across EMS agencies. With the passing of the Bipartisan Budget Act of 2018 (H.R. 1892) and with it, the Ambulance Cost Data Collection initiative, EMS agencies have become wary of increased scrutiny over their business operations and have begun taking a more critical look at their performance, including their approach to billing and collections.

In contrast to the traditional billing operations that once serviced EMS, revenue cycle management (RCM) addresses the common gaps that contribute to revenue loss throughout the transport billing process—from dispatch to cash posting. By leveraging RCM best practices, EMS organizations can optimize quality of care while still addressing payor nuances and maximizing revenue.

4 Commons Gaps That Hinder Patient Engagement & Lead to Revenue Loss

1. Regulatory changes and evolving payer contract requirements make it difficult to stay on top of required documentation. In the case of all transports, validating patient insurance details and capturing patient signatures are all crucial to ensure claims are filed and paid expeditiously. In the case of emergency transports, these details aren’t always available at dispatch and with no “back office” in the back of an ambulance—where treating the patient always takes priority—these details remain uncollected. For non-emergent transports, obtaining prior authorization is a frequent challenge because, while transports occur around the clock, most insurance carriers are only available during normal business hours. Unfortunately, missing any of these details, including patient signature and prior authorization, often results in delayed claim filings and increased denials.

2. Health systems are often hesitant to share patient data due to privacy concerns, even though EMS is part of the continuum of care. As the patient journey progresses from dispatch to transport and arrival at the hospital, data is “trapped” within each vendor-specific silo. Without a fully integrated solution, incomplete and unblended records can hinder agencies’ ability to code at the highest level based on the services rendered, resulting in money left on the table.

3. Lack of timely patient follow-up negatively impacts patient satisfaction and delays payments. When the first phone call a patient receives after a hospital transport is from a collections agency, this can lead to a confrontational patient engagement and more often than not further delays payments. Alternatively, a preemptive call to validate insurance information prior to claim submission can be more productive, improving the overall patient experience and accelerating time to payment.

4. Patient statements lack transparency and are disparate, which has become increasingly problematic with the growing number of high-deductible plans. Post-transport, patients are often left managing multiple bills that correspond with their entire episode of care. Unfortunately, paper statements rarely offer detailed explanation of benefits (EOBs) and provide limited recourse for correcting insurance information or other patient details to ensure accuracy. Coupled with managing the clinical aspects that coincide with an emergency transports, this experience can be extremely overwhelming and inevitably lead to patient discontent aimed at the EMS agency. Moreover, when patients are financially unprepared to pay, unpaid emergency transport bills are ultimately written off. With more than 40% of privately insured Americans now enrolled in a high-deductible health plan (HDHP), according to a recent survey by Health Affairs,3 the risk of unpaid bills is steadily increasing.

High-Tech and Low-Tech Approaches to Close these Gaps

1. Leverage application programming interfaces (APIs) to establish direct connections into a broad array of data sources to enrich data the time of dispatch. By compiling a holistic clinical, financial and administrative profile for each patient at the time of dispatch, teams will be better equipped to flag missing information, validate patient identification, confirm insurance coverage and payer requirements. For tech-savvy agencies, consider leveraging predictive analytics to identify patients’ propensity to pay. These actionable insights can be leveraged both at dispatch as well as post-transport, ensuring claims are complete or triggering workflows to address missing details. For non-emergent transports, pushing this information to the paramedic via the electronic patient care report (ePCR) also facilitates more informed patient engagement.

2. Take the time to educate your counterparts at hospitals about HIPAA limitations and allowances to reduce unnecessary information blocking. Per the U.S. Department of Health and Human Services, the HIPAA Privacy Rule establishes a foundation of Federal protection for personal health information, carefully balanced to avoid creating unnecessary barriers to the delivery of quality health care. Ready access to treatment and efficient payment for healthcare, both of which require use and disclosure of protected health information, are essential to the effective operation of the healthcare system.4 When the topic of patient privacy inevitably comes up, remind hospital administrators and physicians that all healthcare providers including ambulance transport organizations, may use protected health data as part of a claim for payment to a health plan.

3. Use low-tech tactics post-transport to facilitate patient engagement and accelerate payments. At the end of a transport, when patient medical records are provided to either the patient or patient’s care giver, take this opportunity to attach a business card with a link to your agency’s patient web portal. Or, if during the billing cycle your staff uncovers missing insurance information, proactively reach out to the patient prior to submitting a claim with a wellness call. This approach fosters trust, provides the patient an opportunity to address documentation gaps, and reduces risk of claim denials.

4. Optimize your patient portal for the patient experience, not just payment collection. First and foremost, ensure that you mitigate any technical glitches that may hinder a patient’s ability to access your billing site. This may include, but is not limited to, removing outdated URL conventions, maintaining an up-to-date security certificate, and making it mobile friendly. Second, design your patient portal by leveraging user interface and user experience best practices. This helps to create a more intuitive and productive user experience while mitigating data entry errors. Lastly, focus on ensuring billing transparency, including the option to drill-down to specific EOB details, and enabling key features like profile management, insurance updates and electronic signature capture.

In addition to the above high-tech and low-tech options that directly address contributors to revenue loss, consider augmenting your billing team with regulatory experts. The regulatory environment for ambulance transport service organizations continues to evolve at a rapid pace, as evidenced most recently by the Center for Medicare and Medicaid’s newly announced five-year payment model: Emergency Triage, Treat and Transport (ET3) Model.5 To remain current on all regulatory requirements, from the Ambulance Cost Data Collection initiative and ET3 Model to managing revalidation timelines for provider enrollment, many agencies are leveraging consulting services to ensure no deadlines or requirements are missed.  

While simultaneously managing the evolving regulatory environment, payer contract compliance, and increasing risk of unpaid claims may seem daunting, therein also lies opportunity. The first step is leveraging a combination of high tech and low-tech approaches to enrich patient information from dispatch to claim submission, drive actionable insights, and optimize the overall patient experience. In doing so, EMS agencies improve coding accuracy and completeness, foster transparent and unencumbered patient billing, resulting in lower denial risk and accelerated cash flows.


1. Buczyner M. (Aug. 17, 2017.) Unpaid ambulance bills costing the county millions. Retrieved April 26, 2019, from

2. Berkeley Fire Department Ambulance Billing Follow-Up Audit. (March 28, 2017.) City of Berkeley City Auditor. Retrieved April 25, 2019, from

3. Kullgren J, Cliff E, Krenz C, et al. Consumer behaviors among individuals enrolled in high-deductible health plans in the United States. JAMA Intern Med. 2018;178(3):424–426.

4. Uses and Disclosures for Treatment, Payment, and Health Care Operations. (n.d.) U.S. Department of Health and Human Services. Retrieved April 26, 2019, from

5. Emergency Triage, Treat, and Transport (ET3) Model. (n.d.) Centers for Medicare & Medicaid Services. Retrieved April 26, 2019, from