Documenting Medical Necessity 101

Current EMS news is littered with stories of fraud and abuse cases involving ambulance companies and insurance carriers. Some ambulance companies have actually been guilty of shady business practices and others may have been guilty only of ignorance of the law. Either way, verifying medical necessity plays a large role in these negative allegations. The Centers for Medicare and Medicaid Services (CMS) has indicated that $350 million a year is paid to ambulance companies due to fraud or abuse.

Medicare and Medicaid payers will only reimburse for ambulance transport if the service is “medically necessary,” meaning it would have been unsafe or would have caused harm to the patient if they would have been transported by any other means. So, if the patient is able to ambulate, sit up in bed or sit in a wheelchair, these types of patients are normally found to be not medically necessary.

Ambulance companies must not develop key terms for their providers to use, such as “bed-ridden” or “stretcher-bound,” to attempt to justify medical necessity. The patient assessment must be detailed and completely describe the patient’s medical condition to meet the medical necessity requirement at the time of transport. Include the medical care that was required at the time of transport to assure the patient arrived at the receiving facility safely.

Other vague terms that should be avoided in the patient care report include weakness, ESRD, dialysis transport, unknown and even “other.” The documentation of the detailed assessment within the patient care report should describe the body systems affected by the weakness and its limitations. The detailed assessment of the patient should describe what is occurring at the time of transport and why the patient needs the ambulance to transport them to the dialysis center for their treatment.

Unfortunately, some ambulance companies have had their employees remove any terms that might indicate the patient could have been transported by another means of transportation. Each patient care report must be factual and specific in regards to the patient’s condition at the time of transport.

Here are 10 recommendations to avoid investigations, audits and denied claims:

  1. EMS company owners and management must educate themselves on the rules and regulations of submitting ambulance transport claims to insurance companies.
  2. Each EMS company must have a policy in regards to the completion of the patient care report.
  3. Each EMS company must have a quality assurance/quality review program to review patient care reports to assure each patient care report is detailed and complete.
  4. All documentation within the patient care report must be truthful.
  5. Patient care report documentation must be factual and accurate.
  6. The documentation must be detailed and support the medical necessity of the ambulance transport.
  7. Each patient care report must stand alone. Do not copy a previous transport report.
  8. Each EMS company must develop a policy for its staff on how to handle those patient transports that may not be medically necessary.
  9. Do not have a list of key terms to be inserted in all patient care reports to meet the medical necessary requirements.
  10. Make sure you receive a complete, detailed physician certification statement (PCS) for all scheduled non-emergency transports. Each PCS must be signed, dated and indicate the medical reason for the ambulance transport.

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