Understanding the Complexity of Ambulance Billing
In order to understand the complexity involved in Ambulance billing which has also been the cause of much fraud in the ambulance billing services, one needs to understand the workflows, the processes, the changing healthcare reforms, the updated ambulance rules & regulations from CMS, and the compliances that all healthcare providers need to comply with, even ambulance services.
Unlike billing for other medical specialties, ambulance billing is not based on a definitive diagnosis. Here the patient is treated based on their apparent condition when first "met" with.
Coding and billing is done based on the Patient Care Report filed by the ambulance crew along with the additional backing of the "run sheets" as filled in at the time the patient is picked up. Accurate documentation in the Patient Care report (PCR) is of utmost importance, especially for compliance and thereby proper claims. This report has to contain all specific details of the patient's condition which reflect the injury or condition on the patient's anatomy, and also specific terminology is required to be applied, besides Mileage documentation, Level of service in terms of Basic Life Support (BLS) or Advanced Life Support (ALS) service offered - can make a difference to building an effective Revenue Cycle Management (RCM) process. For example, if an emergency call is received for an ALS dispatch, and ALS assessment was conducted, but no ALS intervention was provided, yet the billing was done based on the ALS call, many would term this as wrongly billed! But based on Medicare guidelines this will be rightly billed. Knowledge of the CMS Medicare Benefit Policy Manual should be thoroughly understood by the ambulance billers and coders
For most ambulance services, the single largest payor is Medicare. Medicare is also the payor with the most complex rules, and the harshest penalties for improper billing. Further, Medicaid is managed by each State, so rules vary widely. There are many challenges such as short "timely filing" periods, retroactive eligibility, Medicaid Managed Care, that need to be understood when ambulance service providers file their claims
While most of the codes correspond to parts of the body, there are also modifiers for ambulance services, as for other healthcare providers. But, for ambulance services, the specific modifiers identify place of origin and destination of the ambulance trip which must be submitted on all ambulance claims. The modifier is to be placed next to the Health Care Procedure Coding System (HCPCS) code billed. Incorrect use of modifiers leads to longer processing time and/or denial of services.
For a complaint billing, all valid signatures on documentation are very important. The inclusion of Advance Beneficiary Notices and Physician Certification Statements, are all required for billing to be compliant and avoid denial claims. Beneficiary signature rules, complex issues surrounding required signatures including who can sign on the patient's behalf, and when, is critical to proper billing of Medicare for ambulance billing services.
Verification of the information necessary to properly bill the claim needs to be also obtained by ambulance services, as well as the process of turning the information collected into a payable claim.
Since ambulance services often offer various levels of ground and air ambulance services, here several criteria of what determines "medical necessity" should be known to all parties to determine the proper level to bill.
Compliances need to be adhered to if faster claims need to be processed - National Provider Identifiers, as well as paper claim submission vs. electronic claim submission, knowing the pros and cons are all essential for any ambulance provider to run their service efficiently. Compliance with HIPAA Privacy, Security and Compliancy laws should be known so as to avoid falling into the "fraudulent" category.
Posting & Remittance
Understanding the importance of Remittance Advice that accompanies insurance payments and the payment posting process, including recognizing incorrect payments, and secondary billing of billable balances is very essential to the RCM process.
Not just a good understanding but how this information can be converted into knowledge to have an effective Revenue Management process is very essential for all Ambulance service providers. Knowledge of legal sanctions for violations of Federal health care program requirements, areas of risk, the enforcers and the various penalties for violations, should all be known when running an ambulance service.
The above all include the framework within which ambulance service providers need to work efficiently to maintain an effective Revenue Cycle Management process. However, the processes and workflows too are critical for reimbursement and revenue generation and avoidance of ambulance fraud in the system.