Top 5 Compliance Issues for Ambulance Biller

Ambulance service billing involves a host of unique compliance challenges. The ambulance industry has seen a significant number of false claim cases, fraud investigations, Medicare audit activity, and other types of billing-related cases. It is imperative that billers fully understand the nuances of ambulance reimbursement to be able to successfully sidestep these landmines.

The following are five of the most significant issues in ambulance billing.

This is by no means an exhaustive list but includes some of the most common and serious challenges in the world of compliant ambulance billing.

1. Medical Necessity

Medical necessity is established when the patient’s condition is such that the use of any other method of transportation is contraindicated. In any case in which some means of transportation other than an ambulance could be used without endangering the individual’s health, whether or not such other transportation is actually available, no payment may be made for ambulance services. In all cases, the appropriate documentation must be kept on file and, upon request, presented to the carrier/intermediary. It is important to note that the presence (or absence) of a physician’s order for transport by ambulance does not necessarily prove (or disprove) whether the transport was medically necessary. The ambulance service must meet all program coverage criteria in order for payment to be made.

Medical necessity for ambulance services continues to be the biggest compliance issue in ambulance billing. Like any other type of healthcare service, ambulance transportation must meet medical necessity guidelines in order to be covered. However, when it comes to ambulance billing, the medical necessity standards seem to be vague and less defined than in other medical specialties.

In other words, if a patient could safely be transported by car, wheelchair van, stretcher van, or any other means, then medical necessity is not met, and reimbursement cannot be made. It is important to note that when assessing medical necessity, only the patient’s condition matters; it is irrelevant if those other means of transportation are unavailable.

To put it another way, if the only reason a patient is being transported by ambulance is that they don’t have a car, or that the nursing home’s wheelchair van is out of service, that alone is insufficient to establish medical necessity for ambulance transport. The mere unavailability of other means of transport does not mean that ambulance transport will be covered.

The medical documentation from the ambulance crew at the time of service—the patient care report (PCR)—must clearly establish that the patient required transport by ambulance. This is vital, and ambulance billers will often find that ambulance PCR documentation is not sufficiently detailed or complete to allow for the level of specificity required under ICD-10 coding.

2. Signatures

Medicare and other Payers require the signature of the beneficiary, or that of his or her representative, for both the purpose of accepting the assignment and submitting a claim. If the beneficiary is unable to sign because of mental or physical conditions authorized person may sign the claim form on behalf of the beneficiary. Authorized person can be Beneficiary’s legal guardian, a relative or other person who receives social security on behalf of the beneficiary, a representative of an agency that provides assistance to the beneficiary, a representative of the ambulance provider or supplier who is present during an emergency and/or non-emergency transport.

A provider/ supplier (or his/her employee) cannot request payment for services furnished except under circumstances fully documented to show that the beneficiary is unable to sign and that there is no other person who could sign. Medicare does not require that the signature authorize claim submission to be obtained at the time of transport for the purpose of accepting assignment of Medicare payment for ambulance benefits.

When a provider/supplier is unable to obtain the signature of the beneficiary, or that of his or her representative, at the time of transport, it may obtain this signature any time prior to submitting the claim to Medicare for payment. (Note: There is a 12 month period for filing a Medicare claim, depending upon the date of service.) If the beneficiary/representative refuses to authorize the submission of a claim, including a refusal to furnish an authorizing signature, then the ambulance provider/supplier may not bill Medicare but may bill the beneficiary (or his or her estate) for the full charge of the ambulance items and services furnished.

If, after seeing this bill, the beneficiary/representative decides to have Medicare pay for these items and services, then a beneficiary/representative signature is required and the ambulance provider/supplier must afford the beneficiary/representative this option within the claims filing period, but this creates more work for ambulance billers and can cause significant delays in the ambulance revenue cycle.

3. Advanced Life Support Billing

Another key compliance risk area in ambulance billing is the use of higher-paying advanced life support (ALS) codes in cases where lower-reimbursed basic life support (BLS) codes should be used. ALS levels of service can be billed only when the skills required to care for the patient exceed the scope of practice of an EMT-Basic in that jurisdiction. Therefore, an ambulance biller must know what the approved scope of practice consists of for EMTs in that jurisdiction, and what skills require licensing or certification above that level.

The biggest area of compliance risk with ALS services, however, has been in the application of the so-called “ALS Assessment” rule. Under this rule, Medicare allows the ALS-emergency level of service to be billed when the nature of the ambulance dispatch necessitates an assessment of the patient by an ALS crew, even if the patient does not end up needing ALS interventions. While this rule sounds straightforward on the surface, it has been the subject of much compliance enforcement activity in the ambulance industry in the past few years.

Some ambulance billers improperly conclude that all 911 calls are billable at the ALS level whenever there is a paramedic or other ALS provider responding on the ambulance. This results in significant overbilling, or “upcoding,” of BLS claims to the ALS level. It is not the mere presence of an ALS provider that triggers the ALS assessment rule; an ALS-level emergency call is also required under the EMS system’s dispatch protocols. So, ambulance billers must not assume that every ambulance call with a paramedic on board qualifies for an ALS level of billing.

4. Interventions

Earlier, we discussed the medical necessity for the ambulance transport itself. But the medical necessity for transport has a close relative, and that is a medical necessity for the clinical interventions performed by the crew.

Say, for instance, that an ambulance PCR documents a patient with no complaints, and with normal and stable vital signs, who is being transported to the hospital. The PCR indicates that the patient is ambulatory and that she walked unassisted and without difficulty to the stretcher. The PCR also indicates that the EMT administered two liters per minute (LPM) of oxygen via nasal cannula. A patient with no complaints and normal vital signs would ordinarily not require the administration of supplemental oxygen; though this particular intervention is often used by EMS providers even when there is no clinical indication for it.

In a case such as this, where the documentation provides no basis for the biller to establish medical necessity, the performance of medical intervention—when there is no medical justification for that intervention documented anywhere in the record—should not be used to “confer” medical necessity on a claim where it does not otherwise exist. In other words, interventions themselves must be medically necessary, and it is the job of the EMS providers to document the clinical need for the interventions. It is not the job of the biller to “assume” that medical necessity exists merely because an intervention was performed.

In the event that there are no ALS interventions documented, review the PCR and/or dispatch records to determine if ALL of the following criteria have been met:

  • The initial dispatch required an emergency response; and
  • The dispatch center who handled the call stipulated that the patient’s reported condition at the time of dispatch required an “ALS level” response- based upon approved dispatch protocols; and
  • An ALS Provider arrived on scene and conducted an “ALS Assessment; and
  • The patient was transported to an approved destination such as a hospital; and
  • The transport meets Medicare’s reasonableness and medical necessity standards

Transports that meet all of the above criteria may be appropriately billed to Medicare as an ALS1-Emergency even though no ALS interventions were provided.

5. Training

Finally, an important part of an ambulance billing operation is to ensure that all billers are specifically trained in the unique world of ambulance billing and coding. It is dangerous to assume that billing and coding knowledge from other areas of healthcare is automatically applicable to ambulance billing. Ambulance coding and billing have their own quirks and idiosyncrasies, and billers should receive ambulance-specific training to maximize billing compliance.

Formalized and ambulance-specific coding and compliance training can also help your agency overcome the “whisper policies” that often occur in a billing office in the absence of formalized and standardized training.

Accurate communication is the key to an effective ambulance billing program. Patient care providers at all levels along with ambulance company administrators, supervisory staff, and most importantly the billing office itself must be prepared and well-versed in sorting out these sometimes confusing scenarios.

As we are doing Ambulance Billing for years now, our clients can rest easy that they are protected by our informed knowledge at all levels. If that’s not the case in your world, then maybe it’s time to give us a call. You can reach us at 888-357-3226 or