By Kim Stanley & Matt Zavadsky
EMS has always been a profession built on contradictions.
We are expected to arrive in under 10 minutes, solve complex medical emergencies in someone’s driveway, calm down the family dog, explain Medicare rules and somehow do it all while being told, “You’re just an ambulance ride.”
And now, we’ve entered the next great evolution in prehospital care: Treatment in place (TIP) — where EMS responds, treats appropriately, and the patient doesn’t go to the emergency department.
Which is great for patients. Great for hospitals. Great for the healthcare system. And historically, terrible for EMS financial sustainability. Because nothing says “modern healthcare” like being financially punished for doing the right thing.
But that’s changing. Slowly. Awkwardly. With lots of medical director input, and lots of advocacy.
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Let’s talk about the benefits — and realities — of billing for Treatment in Place.
The big idea: Care without the unnecessary ride
Treatment in place is exactly what it sounds like: EMS responds to a 911 call, evaluates the patient, provides appropriate care and determines that transport is not medically necessary, instead of defaulting to the old model: “You called, we came, therefore you ride to the hospital.”
TIP supports a smarter approach:
- Manage low-acuity conditions at home
- Avoid unnecessary ED visits
- Reduce system overcrowding
- Preserve ambulance availability
- Improve patient experience
In short: EMS finally gets to be a mobile healthcare provider, not just a medical Uber with sirens.
The problem: EMS has been stuck in the “transport = payment” era
For decades, EMS reimbursement has operated under one simple principle: No transport, no pay. EMS has long been funded as if our only billable skill is driving. Never mind the assessment. Never mind the treatment. Never mind the fact that we prevented a hospitalization. Historically, the system has rewarded only one outcome: Patient in ambulance → ambulance moves → claim gets paid. TIP breaks that model, which is exactly why it’s both promising and complicated.
The benefits of billing for treatment in place
1. It aligns payment with modern EMS practice
EMS is already providing high-level clinical care in the field:
- CPAP
- Naloxone
- Glucose management
- Behavioral health stabilization
- Community paramedicine interventions
Billing for TIP acknowledges that care happened, even if wheels didn’t roll.
It’s reimbursement catching up with reality — about 20 years late, but still ...
2. It helps EMS systems stay available for real emergencies
Every unnecessary transport ties up:
- Ambulances
- Crews
- ED beds
- Hospital staff
TIP allows EMS to treat appropriately and return to service faster.
That means when the next cardiac arrest drops, the closest unit isn’t sitting in an ED hallway waiting for ED bed 42B.
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3. Patients actually prefer not going to the hospital
Contrary to popular belief, most patients are not thinking: “I hope I spend 6 hours in the ER tonight.” Many want reassurance, treatment and a plan, not a waiting room. TIP supports patient-centered care, especially when paired with follow-up resources.
4. It creates financial sustainability for progressive EMS models
Here’s the uncomfortable truth: EMS cannot innovate on bake sale funding.
If we want EMS to deliver:
- TIP
- Alternate destinations
- Hospital-at-home support
- Behavioral health crisis response
- Preventive care interventions
EMS must be paid for outcomes beyond transport.
Billing for TIP is one of the pathways that makes that sustainable.
The realities (because this is EMS, after all)
Reality #1: Billing TIP is not “free money”
Some folks hear “treatment in place reimbursement” and think: “Finally! We’ll be rich!” Let’s all laugh together. TIP billing requires:
- Medical director approval
- Protocol compliance
- Medical necessity documentation
- Payer-specific rules
- QA review
In other words, you don’t just write: “Patient didn’t want to go. Vitals fine. AMA-ish,” and send Medicare or other payers an invoice.
Reality #2: Not every payer plays nice
Medicare tested TIP reimbursement through ET3-style models and waivers, but broad adoption is uneven. Commercial insurers vary wildly. Medicaid rules differ state by state.
Reality #3: EMS must be ready to defend clinical decision-making
Transporting everyone is easy. Treating in place requires judgment — and accountability. Agencies must ensure:
- Strong medical director involvement
- Strong protocols
- Clinical training
- Clear documentation
- Iron-clad quality assurance
Because the question will come: “Why didn’t you transport?” TIP reimbursement only works if EMS providers are treated and trusted as healthcare providers, ones that do not simply talk people out of going to the hospital because it’s inconvenient for the patient and the EMS agency.
A strong QA program that identifies TIP is both safe and effective is crucial. For example, you should know how often a patient who is treated on scene without going to an ED calls 911 again, or shows up at an ED, with a similar chief complaint as the original EMS response.
The bottom line: TIP billing is about more than revenue
Billing for treatment in place is not about “charging for doing less.” It’s about recognizing that:
- EMS care is valuable
- EMS decisions matter
- Avoiding unnecessary transport is good medicine
- Sustainability requires reimbursement aligned with reality
EMS is evolving.
The reimbursement system is … jogging awkwardly behind us, slightly out of breath.
But TIP billing is one of the strongest signs that EMS is finally being seen as what we’ve always been: A critical healthcare service, not just a ride.
In summary ...
Treatment in Place is the kind of progress EMS has wanted for decades: Smarter care. Better outcomes. More efficient systems. Now we just have to do what EMS always does:
- Build the plane
- Fly the plane
- Document the benefits of the plane
- And convince someone to reimburse the cost of the plane
All at the same time.
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ABOUT THE AUTHORS
Kim Stanley is the chief client advocacy officer for EMS|MC.
