A Cautionary Tale

Steve McCormick, MBA, EMT-P

So, I lost a client this week. 

Now there’s normally one or two reasons a client leaves a service company, and I get and accept that. A provider either doesn’t like the results they’re getting, they don’t get along with their point person, or more common, the new manager wants to use their last service because “they know them.” Well, this client falls into the “doesn’t like the service they’re getting.” So, shame on us right? Maybe.

This was different. This loss is all about the current state of our system. The state of Medicare and Medicaid’s decreasing reimbursement. The reality that we must do more and more work for less and less cash collection. The fact that payers are truly getting the upper hand. The fact that those same payers are adding roadblock after roadblock all in order to use the clock against providers to encourage an even deeper negotiated discount. Worst of all, this was about a provider not willing to do anything in their control about it.

We are what I like to call a “boutique service” offering our expertise and staff to the smaller providers in EMS. We do the gambit of back-office tasks and also a fair amount of consulting and training. We’ve been in operation for almost 25 years, the last 22 under my umbrella. Prior to this, I practiced paramedicine for some time. I was afforded an opportunity to see multiple operations around the country, and their individual struggles as well as successes.

All of that allowed me to be able to see when an owner is being deceived by their staff or facility contracts. It also allowed me to see the best in our community and let me watch bad providers shut down – and those left trying to catch the fallout. Of late, this has allowed me to see some owners who won’t do what’s necessary to help their own operation.

What’s necessary, you ask? In my opinion, be consistent. Be flexible. Be aware. Be willing. When we run a code, do we run it based on the patient’s sex? Size? Injury? Pre-existing condition? No, we run these the same way every time, and it hit me years ago why this is so.  Because then it’s consistent. I shouldn’t forget a step if I do the thing the same way every time.     

In non-emergency medicine, we must prove some things to be paid appropriately. The only “vehicle” we have to do that is our report, the “ePCR” in most cases now. As an aside, when new providers ask me what ePCR software they should get, I always answer with this: pen and paper. If you cannot write a good report on paper, then no computer software will fix that.

Related

So, the art of writing of a good report is a skill that is cultivated over time. It’s not something that just pops in on day one. And to be fair, there is no perfect report. I’m not going to talk much more about that, but I am going to talk about the practice of medicine. Or in the case of my client loss, the lack of practicing of medicine.

Don’t get me wrong, I’m certainly not saying that this one client is the only client I feel this way about. No. But, this loss was a culmination of so many things happening around us and to us, that contributed to this cautionary tale. And maybe a tad of anger on my part. 

It started a long ago when the practitioners of this operation were allowed to get away with not taking a second or third blood pressure. Then not describing the patient fully. Then not writing about the medically necessary reason the patient needed transport. Then not collecting supporting paperwork, and on and on. You can see the picture here. 

As I audit providers, I can immediately see which operations really care and those that do not. I can also “see” which EMTs at every level are actually practicing medicine, and those that are not. Our general manager had been attempting to encourage this provider to write a better report all to no avail. The provider started calling me for help. “Where is our cash?” “What are you doing?” “What are you going to do?” Then a few payments would arrive and they would be calm for a while. Under the surface however, the other problems were lurking: the lack of good reports, the lack of paperwork, the lack prior-authorization numbers (PAN).

Another phone call: “We’re going to have to close our doors if ‘we’ don’t do something.”

“OK,” I said. “I’ll take a hard look.”

As I met with staff and the GM, an unfortunate, disturbing, and I hate to say, potentially systemic picture came into view. The PCRs were just horrible. There was no reason for anything. No discussion of medicine practiced, no therapies delivered, no vital signs taken as a protocol might prescribe. Up to the point that the written words, “patient refused vital signs” were commonplace. What? 

There were no head-to-toe descriptions. The only reference was, “head to toe unremarkable,” and then it hit me. Nobody is doing a head to toe. What?

There were no PAN numbers present. No hospital face sheet or any documentation other than the “empty” documentation on a PCR. There were no Social Security numbers (SSN), except the words “SSN on file.” It turns out there was no full documentation on any single patient of any type in this entire inventory of transports from the provider. No wonder the back office is fighting so many denials and no wonder they are becoming final denials. No wonder the owner is scared and angry at no cash, angry at the payers and angry at me.  While there was some demographic information obtained, there wasn’t much from the batch I was auditing. Kudos to the back office staff for filling in all those blanks.

So, I called the provider and asked for a meeting with them with their supervisors. Yes, we need help. Yes, we need input. So we have a separate call with all supervisors and staff.

Me: “Going forward you need a new face sheet on every patient every day. You need supporting docs from the facility at time of pickup.  These payers require a PAN before the patient is in your ambulance. You can fax the request with a date and time stamp so at least we have that to fight with.”

Them: “No, we cannot do any of that. We can’t get paperwork, and waiting for a PAN won’t work ‘cuz then the facility will call a different provider, and someone else might get the job”.  

Me to myself: What?

Also me: “And your staff need re-training on how to write a report based on the medicine that they practiced.”

Them: “OK, we can identify a supervisor that will take your training.” 

Me to myself: Well, that’s something. 

Not a week later their GM calls me and tells me to stop helping, “’cuz it’s just too much.” I’m overwhelming the staff with requests. 

Them: “We’ve always done things this way and it’s worked just fine.”

And the rest of the picture was clear.  The owner doesn’t want to rock the boat: The manager doesn’t believe that they can get paperwork: The supervisors do not manage the staff to do their jobs, and so, the inmates are running the asylum.

I get a call a few weeks later.

Them: “We’re cancelling our agreement. We don’t feel you’re working hard enough on our business, and we don’t feel important to you so were moving on. We’ve found another service.” 

Me: Huh. OK. “OK are they cheaper?”

Them: “No. Actually they are more expensive.”

Me: “OK then. Thanks for your candor.”

Meanwhile, the paperwork is as bad or worse. No positive changes whatsoever in any category. This provider has a mess, but worst of all, they seem incapable of taking ownership of any issue. 

I’ve done this for a long time. When we have created an issue, we say so. When we’ve made mistakes, we admit them. I’ve even fallen on my sword when not needed just to appease. But this is different. 

For any owner in EMS today, not willing to accept less profit, and unwilling to manage their staff, this is your future. Do not let this become the face of EMS.

To all EMS providers: Practice medicine and write about it. In the non-emergent transfer segment, we are complacent. How dare we. Non-emergent medicine is where we can learn the most medicine. Take advantage of that. Touch your patients! Look at your patient’s malady. Look at the wound, the broken limb, the color of skin. Ask questions. Deliver oxygen as necessary. Add an IV when appropriate. When do we not do a head to toe? The answer is never. We always do a head to toe, not a quick scan. Do not take someone’s word for a thing. You must practice your own medicine. Practice medicine! That is your job! So, do the head-to toe every time! Patients do not refuse to have their vitals checked for the most part.  Patients expect to be poked and prodded and cared for. That’s the job of medicine. Don’t forget it. Then writing the report will be a piece of cake! 

To all the owners/administrators: Know the laws. Know what it means when they are not followed to the T. Create processes to gather PAN numbers. The word “pre” is paramount. A denied claim for lack of PAN is not fixed by trying to get one after the fact. It’s not a “post” auth number.

Hold your supervisory staff accountable. Fire them, demote them if you must. Say “no” to some patients. It is ok to say “no.” “Lift up” the street staff. Respect them for the job they do, or do not do. You think you’re running your company, oh no. You’re not running anything. The EMT in that ambulance with the one hour of time with that patient. That person is running your company. Make sure they know how to do so. Make sure they know why they are gathering paperwork, and writing an essay for a two-minute transfer. If they are not writing an essay, then figure out why not. Do not just let it go. And give them time to write those essays! What does your physician advisor think of the “written” medicine your crews are practicing?

Yes, so I lost a client this week. It wasn’t the first and certainly won’t be the last. But I can guarantee you, there are a lot more pre-audits coming for my future clients from many sources. So, be ready.

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