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Policies and procedures are essential components to have to be able to meet the compliances in the healthcare industry today. These documents provide the Compliance Officer, executive management and the workforce with an understanding on what is expected and how to operate.

Given the fraud that has happened in the ambulance service healthcare delivery, vigilance is even more now from the Centers of Medicare and Medicaid (CMS). The first document that should be developed and distributed, at least among staff, should be the Standards of Conduct or Code of Conduct. This document must integrate:

  • Commitment to compliance with all federal and state standards by all staff from top down
  • The organization’s goals, mission and ethical requirements – which should be clearly be informed to ambulance crew every 3 months at least.
  • Certain basic standards of performance from all members of the ambulance service right from management to workforce.

However, when it comes to Ambulance billing where fraud is eminent certain Policies and procedures should be maintained. In order for the policies and procedures to be effective, they must be tailored to the operations of the provider and be supported from the top-level management that throughout the organization. “Boiler-plate” policies and procedures will not work except as guidelines.

Policies should cover:

  • Billing for items or services never provided: The transport must be medically necessary and reasonable. Moreover, the mere presence of a physician’s order for transport by ambulance does not necessarily prove or disprove whether the transport was medically necessary.
  • The documentation that provides the strongest support to establishing medical necessity is the patient care report (PCR), which is essentially a medical record documented by the treating emergency medical technician (EMT) or other provider, detailing the patient’s condition and interventions performed during the transport. This is very essential for the Billing team to be able to increase revenues and still not commit fraud.
  • Ambulance providers must ensure that transports billed to Medicare meet certain “origin” and “destination” parameters, have physician certification statements on file, and are coded with the correct level of service provided. Any miscommunication and wrongly coded or entered data during this process could lead the ambulance provider to either facing a civil and/or criminal liability.
  • The non-emergency side of the ambulance transport industry which includes what is known as repetitive transportation for especially patients suffering from dialysis, needs to be more vigilant and very clear documentation should exist.
  • Appointing an individual with a clinical background (ideally a registered nurse, but at least a paramedic) to conduct a pre-transport on-site evaluation of the patient.
  • Regular & Effective training and education should be part of the policy of any ambulance Billing Service. It is one of the most important elements of a compliance program, as it helps the ambulance staff to understand & integrate the policies and procedures into practice; and also keeps them updated about new regulations and rules brought in by CMS and other healthcare providers.
  • Zero Tolerance towards fraud: A hotline number which keeps the channel open for reporting of compliance issues without any retaliation in line with the zero-tolerance of fraud should be in place. Without empowerment in place, a truly effective reporting of compliance issues cannot be ensured.

Procedures when Billing in Ambulance service:

  • Train the communications personnel for different kinds of call intake & dispatch, and on identifying Medicare repetitive patient transports when scheduling requests are received.
  • Screen for initial dispatch process. The process would be used to evaluate the patient’s condition and make an initial determination of whether or not the patient meets the CMS definition of medical necessity.
  • When on site evaluation is conducted it should be extremely detailed and include information on where the patient currently resides the patient’s personal and insurance information; information on the type and location of the destination facility; and information on the type of treatment the patient will be receiving at the transport destination. Onsite evaluation of the patient’s condition is a must and should be noted in the Patient Care Report as this is very essential for the medical billers and coders of the Ambulance Service.
  • For repetitive patients, the evaluator should conduct a short-form re-evaluation of the patient to ensure their condition continues to meet medical necessity.
  • The compliance officer should continually audit and monitor the repetitive patients and an accurate list or database of all current repetitive transport patients should be maintained and audited.
  • Billers need to refer to the Patient Care report, and recheck with ambulance crew to properly identify the right codes and modifiers to be employed.

The compliance officers must emphasize that Compliance is not just about abiding by rules and regulations; it also involves setting up best practices in patient care documentation, billing, and quality of care so as to bring about a more effective and efficient Revenue Cycle Management (RCM) Process .

Published By - Medical Billers and Coders
Published Date - May-12-2016 Back

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