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7 federal payer expectations of EMS

Here are the seven expectations all ambulance services should strive to meet when dealing with Medicare, Medicaid and other federal payers


By Daniel J. Pedersen

Significant federal compliance changes make it more important than ever for EMS leaders to adhere to the federal laws governing compliance with Medicare and other payers.

Newly proposed rules seek to dramatically increase penalties for federal False Claim Act violations. Recent final regulations provided clarity to overpayment refund obligations. The federal government is spending a record amount of money investigating allegations of false and fraudulent billing. With government enforcement, and FCA allegations in the health care industry at all-time highs, it is critical to carefully evaluate the obligations owed to government payers.

Just as ambulance services must treat its patients with respect and compassion, the theme of "Avoid a lawsuit with these 7 public expectations of EMS," an article by Steve Wirth it is important to treat the federal payers with that same respect, as well as with honesty and integrity when submitting claims and receiving reimbursement. Here are the seven expectations all ambulance services should strive to meet when dealing with federal payers, which includes insurers like Medicare, Medicaid, TRICARE, CHAMPVA, Medicaid HMOs and Medicare Advantage plans, as well as other governmental insurance programs:

1. We will know the applicable payer standards.

Although called Centers for Medicare and Medicaid Services, this does not mean the Medicare Program and the Medicaid Programs follow the same rules. Prior authorization requirements, signature requirements and distinctions between ALS and BLS can vary from state to state and payer by payer. For all federal payers it is important for:

  • Call-intake and dispatch personnel to be aware of any prior authorization requirements.
  • Crewmembers to know about special patient signatures requirements.
  • Billers and coders to be cognizant of nuances in the billing requirements.

2. We will refund identified overpayments.

The FCA requires identified overpayments to be refunded within 60 days. The failure for an EMS agency to do so risks an FCA violation and its steep penalties. Sweeping problems under the rug is not an option. Performing compliance reviews to identify potential overpayments and taking steps to refund such overpayments is an integral part of the overall ambulance operation.

3. We will bill services rendered to hospice patients properly.

One of the most misunderstood elements of ambulance billing involves patients who have a terminal illness and have elected hospice. Knowing whether to bill insurance or the hospice relies on call intake information and continues with data obtained by the crew. Just because a patient may be a hospice patient does not mean hospice is billed. Information about the terminal illness and whether the illness relates to the reason the patient is being transported determines which payer is financially responsible.

4. We will bill facilities at an appropriate rate (no improper discounts).

Hospitals and skilled nursing facilities, just like ambulance services, are fighting hard to remain profitable in an ever-changing world of health care reimbursement. As a result, these facilities want to find ways to save money, including entering into low-rate contracts with ambulance services.

While most ambulance transports are separately billable to insurance when medical necessity and other coverage criteria are met, there are certain transports for which a facility is financially responsible. Agreeing to a discounted rate, which is anything less than fully-loaded, average cost per transport to perform the transport poses compliance risks under the federal Anti-Kickback Statute.

Because the facility is in a position to refer business to the ambulance service, offering a discount to the facility is giving something of value in exchange for referrals, which is a classic AKS scenario known as swapping. It is necessary for marketing staff, contracting agents and other managers responsible for obtaining contracts with facilities to be aware of the AKS risks when entering into contracts and setting rates with facilities.

Keep in mind that the thing of value doesn’t just apply to the charged rate. Giving a referral source anything of value, including free pizza parties, event tickets, training, cash and other perks to win a facility’s business can trigger an AKS violation.

5. We will enter into legitimate arrangements with municipalities.

Many ambulance services are eager to obtain municipal contracts because having access, even as second or third due response, to emergency transports from a municipality can be lucrative. Unfortunately, just as offering a discounted rate to a facility can pose risks under the AKS, offering anything of value to a municipality to win their business poses risks.

The municipality is in a position to refer business to the ambulance service — for example granting access to ambulance transports within the municipality. When entering into contracts, responding to RFPs or soliciting new business, ambulance services must be careful to avoid offering anything of value, including cash payments, free trainings or gifts that can influence the selection of that provider. 

6. We will not improperly waive co-payment obligations (unless specifically permitted).

Many federal payers, especially Medicare, use a system where the patient shares in the cost of the health care. This financial obligation is known as the co-payment. It is designed make the patients more aware of the costs and to be efficient users of medical services.

Agreeing to waive co-payments poses risks under the AKS as it is viewed as offering something of value to the patient, since it can be seen as an inducement for the patient to use that ambulance service in the future. Although there are several exceptions in which copayments may legitimately be waived, such as a patient’s true financial hardship, billers, coders, managers, owners and marketing staff at the ambulance service need to be aware of these exceptions, and follow the general requirement of making reasonable collection efforts of outstanding co-payments.

7. We will follow all applicable state and federal laws.

Many government payers defer to state laws for vehicle, crew and scope of practice requirements. Failing to meet state ambulance requirements can jeopardize ambulance reimbursement.

Federal payers require all coverage criteria be met for reimbursement to occur, including meeting state laws, not just direct reimbursement requirements. This means the service’s license must be in good standing and the certifications or credentials of all providers on the call must be current and up-to-date.

Similarly, criminal convictions of certain federal and state laws can lead to individuals to be excluded from participating in the Medicare Program. This means that any service rendered by that excluded person makes the claim ineligible for reimbursement.

This is not limited to the actual health care provider, such as an EMT or paramedic. Exclusion can extend to call intake/dispatch personnel office staff, billers/coders and company owners. Failing to periodically monitor staff for possible exclusions can result in serious compliance risks. See the OIG website for additional information about exclusions.

Meeting the seven expectations of the payers is the lifeblood of our existence as ambulance services. 

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