Medicare can cause a lot of headaches for air and ground emergency medical service (EMS) billers. What should, in theory, be a straightforward reimbursement process often turns into payment delays, denials, and payment reductions when payer requirements are not met or only partially met. Not getting the maximum reimbursement for services rendered affects an agency’s bottom line that ripples into budgeting, staffing, and other financial consequences.

Start With Knowing Medicare Requirements

The Centers for Medicare & Medicaid Services (CMS) has set the standard for requirements that many commercial payers have also adopted. Unfortunately, the strict fraud protection and validation rules that must be met for CMS to dispense funds can make billing even more complex.

In order to receive Medicare reimbursement, EMS providers must prove:

1. Actual transport of the beneficiary (patient) occurred, including submission of a complete medical record describing the transport, along with several required signature documents.

2. The beneficiary was transported to the “closest appropriate facility” (i.e. not always the preferred or best receiving center) that can deliver the required care for the patient’s condition.

3. Ambulance transport is medically necessary (i.e., the beneficiary’s medical condition is such that any other forms of transportation would be medically contraindicated via time criticality, distance, risks involved, etc.).

4. The provider meets all applicable vehicle, staffing, billing, and reporting requirements, including billing for services rendered by compliant providers, licensed services, accredited transport, and state/federal data transmission rules.

All of these Medicare requirements must be met in order to receive payment. Claims may be denied if they do not meet these requirements, or retroactively denied if it is determined after payment that requirements were not met (this becomes classified as an “overpayment”). Alternatively, if some, but not all, of these requirements are met, payment could be delayed.

Take 3 Steps To Protect Revenue Integrity

There are three key steps that agencies can take to better ensure revenue integrity in compliance with Medicare’s complex requirements:

1. Set up clearly defined policies, procedures, and best practices that can manage expectations for EMS billers.

2. Implement data validations into electronic patient care reports (ePCRs) that can slow crews down in stressful situations on-scene and increase the likelihood that all required information is being recorded (see more below).

3. Leverage technology and services that can take ownership of these two factors to allow crews to focus more on what they do best: patient care.

A Word on Data Validation

When agencies apply data validations, or rules that must be followed before closing an ePCR, crews can be guided through capturing the critical data necessary for compliant billing. Data validations can cover any aspect of documentation, whether clinical, medical, legal, billing-related, or even documentation-specific. With data validations, EMS agencies can enhance their data collection, improve the quality of their data, and fundamentally optimize documentation. Data validation technology and analytics within configurable ePCR software gives EMS service leaders the tools and monitoring capabilities they need to knock down the barriers to timely delivery and integrity of revenue received.

For more on how to configure data validations, how to determine whether to require fields or use warning prompts, and how to leverage technology and analytics, download the eBook, “Ground and Air Ambulance Revenue Integrity: An EMS Biller’s Guide to Medicare, ePCR Software Configuration, and Faster Reimbursement."

Revenue integrity cannot be achieved without coordination between dispatch, crews, and billing teams. With good policies and procedures implemented, expectations set, and data validations established for quality control, revenue can be protected and the speed of reimbursement will be improved.

Read More About Revenue Integrity:

Configuring Patient Charts: Your Path to Revenue Integrity and Reducing Reimbursement Delays