Fiscal things that can go bump in the night

From changes in the payor mix to compliance issues and data breaches, don’t hide under the covers when fiscal challenges rear their ugly heads

By Anthony W. Minge, EdD

“From ghoulies and ghosties and long-leggedy beasties and things that go bump in the night, Good Lord, deliver us!” — Scottish saying

Have you ever heard that noise in the middle of the night? You know, the one just when you are dozing off and there it is … thump! And you whisper, “What was that!?” Do you lay there, frozen still, intently listening, wondering if you really heard something? Or do you get up, flashlight in hand, in search of this distressing and unexplained sound? Do you check under the bed, in the closets, and maybe even have a peak in the basement? Or do you pull the covers up over your head and try to pretend you didn’t really hear anything at all … just the wind, an alley cat rustling through the garbage, or something else relatively harmless?

Monitoring volumes by acuity level, and not just total trips, is very important. Significant shifts in acuity level volumes (even if your overall number of transports has not drastically increased or decreased) could be a sign of documentation or billing problems.
Monitoring volumes by acuity level, and not just total trips, is very important. Significant shifts in acuity level volumes (even if your overall number of transports has not drastically increased or decreased) could be a sign of documentation or billing problems. (Photo/Pixabay)

The source of that anonymous clatter could be as simple as the foundation settling, old pipes gurgling, or a tree branch rustling against the house in the wind. While each of these are seeming harmless, they may actually be signs of bigger problems and you should be paying closer attention, seeking out the source and finding a remedy before that innocuous sound leads to a much bigger problem down the line.

Now, you’re probably wondering what this has to do with running an ambulance service. The fact of the matter is, there are also things that go bump in our night in EMS. And they are equally scary and can be very costly. Most of the time, these end up being something fiscal in nature, or more simply put, an unplanned expense.

Like many of the noises that go bump in the night at home, we try to rationalize and hope they’ll just go away. However, it’s more likely that they won’t. And much like those untended noises from the house, they’ll probably cost you big money if you don’t address them in a timely manner.

EMS fiscal problems lurking in plain sight

In this case, night doesn’t necessarily mean when all the non-EMS people in the world are immersed in peaceful slumber. Rather, it is any time when you’ve turned your attention to other things. The bump might be an e-mail, a conversation, something you read in a trade publication or saw at a tradeshow, or an employee complaint. But you’re mistaken in your belief that if you put your head back under the covers of daily operational duties, it will just go away.

Here are just a few fiscal items that may be lurking in your EMS closets and under the bed, just waiting for you to snuggle in, only to then scare the economic willies out of you with that bump in the night.

  • Change in volume. Changes in volume can have a significant impact on the stability and sustainability of a service. Some changes are predictable, like coming to the end a revenue stream or contract. Other times, these can occur gradually … creeping along in the night until they finally grow big enough to get our attention, and by then it may be too late. Monitoring volumes by acuity level, and not just total trips, is very important. Significant shifts in acuity level volumes (even if your overall number of transports has not drastically increased or decreased) could be a sign of documentation or billing problems.
  • Change in payor mix. Payor mixes for EMS are destined to change over time. At present, almost 100 percent of the agencies in the United States are seeing an increase in the number of Medicare transports. This is obviously due to the rising number of Baby Boomers who are reaching retirement age and becoming eligible for Medicare benefits. Other things can be moving the needle on the payor mix though, and they may not be as readily apparent if you are not keeping a close watch. For instance, patient dumping still occurs and EMS agencies can get caught in the middle. Transporting a significant amount of these under-insured or uninsured patients can negatively impact the cost budget (although volumes may even be up) of an organization. Changes in the billing department, such as turnover or insurance verification could have a payor mix impact too. When insurance is not appropriately verified at the time of billing, it can slow the revenue stream to a crawl. Keeping a regular pulse check on your payor mix can give you early warning and possibly prevent a small issue from turning into a bigger one.
  • CMS audits. There is a new “old” saying in healthcare: If you haven’t been audited, just wait, your turn is coming. This reality is coming true more often than not, but it doesn’t have to be the monster lurking in the dark. There is no need to be afraid of an audit if you are confident in your billing practices. An active QI program, combined with regular claims and process reviews will keep you from being caught off guard. These fail-safes give you the opportunity to identify potential problem areas, correct errors and even make the appropriate refunds or disclosures if necessary.
  • Compliance. Compliance issues are one of the biggest bumps currently keeping industry leaders awake at night. Failure to check exclusion logs, provide annual HIPAA, HiTech and other compliance related training, not having a compliance reporting mechanism such as a hotline or not following up on the complaints is coming back to haunt EMS agencies nationwide. A robust compliance plan is no longer a wish-list item; it’s a requirement if you plan to get a peaceful night’s sleep.
  • Data breaches. Other demons lurking in the dark include theft and security breaches. These bumps can cost an agency thousands of dollars. The petty thieves, as well as the big-time crooks, are out there, internal and external to our agencies. Patient health information is being stolen with greater frequency in EMS. Many agencies are easy targets, simply because they’ve ignored or tucked that fear away, thinking that it only happens to big healthcare organizations.
  • Errors and accidents. Finally, organizations where the fear of retribution and punishment is so great that no one is going to report an accident are infested with gremlins. Significant costs can be associated with unreported errors, unsafe practices and careless operations. Having appropriate reporting mechanisms and a Just Culture environment can assist in reducing the risks.

Lots of fiscal things can go bump in the night in EMS and many of them can be downright scary. They can have a very negative impact on your bottom line and your ongoing operations. When you hear unsettling noise at your agency, be proactive. You’ve got to look in your agency closets and under the beds, behind squeaky doors and in the basement. Make sure none of these destructive creepy-crawlies are lurking around your EMS organization.

In the meantime, I’ll leave the nightlight on for you.

About the author

Anthony Minge is a senior partner with Fitch & Associates, LLC and serves as the firm’s subject matter expert for EMS revenue cycle management and compliance. He also oversees the BTS, ASM and CCM educational programs, and is co-chair of the Pinnacle Leadership Conference. He holds Doctorate in Organizational Leadership and has over two decades of healthcare billing, finance, operations and leadership experience. He can be reached at

This article, originally published March 20, 2019, has been updated.

Recommended for you

Join the discussion

Get Paramedic Chief in your inbox

Thanks! You've been successfully signed up for the Paramedic Chief

Copyright © 2023 EMS1. All rights reserved.