Most ambulance services in the U.S. bill Medicare and other payors for their services. Unless you’ve been living under a rock the past couple of years, you know the rules on medical necessity and other coverage criteria have tightened considerably, and that federal and state agencies have multiplied their efforts to crack down on improper billing by ambulance services. Healthcare fraud has been an obvious target. But sometimes even the “good guys”–conscientious, compliant EMS agencies–can get caught up in the increased scrutiny that seems to attach to almost every ambulance claim these days. Even the most well-meaning ambulance services can find it tough to do things properly given the maze of confusing, poorly worded and inconsistent laws, regulations and “guidance” from Medicare and their contractors.
EMS medical directors can play a more central role in helping ambulance services effectively deal with the new realities in Medicare and other government healthcare programs. The following are just a few areas where a fully-engaged medical director can enhance your agency’s compliance efforts.
Establishing Defensible Dispatch Protocols
Medicare payment rules reflect several important areas where clinical judgment figures centrally in whether an ambulance claim is reimbursable, and at what level. For instance, Medicare defers to local medical dispatch protocols for making a determination on whether a claim is properly billable at the emergency or non-emergency rate (emergency claims, of course, are reimbursed at a higher amount under the Medicare fee schedule). Although many EMS systems use “national” dispatch protocols, such as medical priority dispatch, many use locally developed protocols for making emergency dispatch and deployment decisions. If a call triggers an emergency response based on these dispatch protocols, the responding ambulance service can properly claim higher, emergency-level reimbursement (provided, of course, that medical necessity and other coverage criteria are all met). These protocols, however, cannot indiscriminately classify every type of call as an emergency merely to take advantage of the reimbursement rules; they must be reasonable and medically defensible in order to survive a Medicare audit in today’s heightened enforcement environment.
This is one area where a fully engaged EMS medical director can play a key role. Helping your system develop–and document–medically defensible emergency dispatch protocols can help prospectively facilitate proper billing determinations, and give much-needed guidance to your billers when reviewing documentation.
A related area for effective prospective “reimbursement medical direction” is the development of clinically based ALS response determinants. These establish when an ALS response is medically justified based upon the patient’s reported condition at the time of dispatch. Even all-ALS systems must have medically appropriate response determinants because Medicare’s “ALS assessment” rule will legitimately pay at a higher ALS rate, even when no ALS interventions are performed, when a qualifying ALS-level emergency response is dispatched.
Again, medical directors can help develop clinically-defensible ALS response determinants to guide and defend this process.
ALS Drug Administration Policies
Medicare recognizes both “ALS Level 1″ and “ALS Level 2″ ambulance claims. The higher ALS-2 level requires the performance of certain manual skills (e.g., manual defibrillation or endotracheal intubation) or the administration of three or more qualifying medications. These can be the same or different medications. However, if the three medications are the same drug, Medicare will allow higher ALS-2 reimbursement only when the three medications are legitimately administered in separate dosages under local clinical guidelines. Medicare does not allow ALS-2 billing when one dosage of a medication is given fractionally in three separate administrations.
How a medication should be administered, of course, is a matter of medical oversight (both prospective and online) and these policies and clinical protocols should be clear and well-defined. When a clinically appropriate medication administration protocol or standing order directs that three separate dosages of a certain qualifying drug be given, the trip would legitimately be eligible for higher, ALS-2 reimbursement.
Specialty Care Transports
Medicare recognizes the specialty care transports (SCT) level of reimbursement when performing an interfacility transport of a critically ill or injured patient who requires care or specialized monitoring beyond the scope of practice of a paramedic. This could include a “paramedic with additional training” as determined by state or local law.
Medicare defers to state law to determine what falls within the paramedic scope of practice in that jurisdiction. Some states allow local EMS medical directors to provide more training to permit paramedics to perform additional skills. Some formal programs (e.g., the “critical care paramedic” program) exist to provide this type of training.
SCTs represent another area where EMS medical directors can play a pivotal role in compliance. Medicare does not define the term “critically ill or injured” for purposes of the SCT rule. Thus, medical directors can help establish guidelines for determining the type of patients who may be appropriate for such transports.
In addition, local medical directors can establish curricula and verify the skills of paramedics who receive the “additional training” necessary to be qualified to perform SCTs.
Medical Necessity Reviews & Claim Appeals
Another area in which medical directors can pay compliance and reimbursement dividends to EMS agencies is to support the process of making and defending medical necessity determinations. This is particularly true for non-emergency and repetitive patient transports, such as dialysis trips. These have been particular areas of focus for Medicare and other enforcement agencies over the past decade.
Medical directors can:
- Help establish appropriate intake processes to pre-screen non-emergency patients;
- Help billers review those “tough cases” before claims are filed; and
- Make “physician-to-physician” appeals to help the ambulance service obtain records from facilities that are often reluctant to provide them to ambulance services–although the Health Insurance Portability and Accountability Act (HIPAA) clearly permits it.
Medical directors can also serve as expert witnesses in Medicare telephone hearings and appeals to help the hearing officer understand the reasons that transport of the patient by other means would be contraindicated (Medicare’s ultimate standard for medical necessity).
These are just a few areas in which EMS medical directors can play central roles in helping ambulance services survive and prosper in today’s healthcare environment. Of course, a well-drafted contract between the ambulance service and the medical director, prepared by knowledgeable legal counsel, is also recommended.