Claim Only the Truth

Editor's note: Emergency 4-1-1 will be a quarterly column in 2008. If you have a topic you'd like us to address, e-mail nancy.perry@cygnusb2b.com.

     As we start the new year, I want to tackle a couple of disturbing issues I see come up time and time again. These are issues that cause significant problems for many ambulances services and their principal employees, and give our entire profession a bad image.

Nonemergent Transports
     First is the issue of nonemergent transports. Last year I gave nine lectures with EMS Consultants, Ltd.'s annual seminar series. I spoke at several state association meetings, at EMT schools and at EMS EXPO. At all of these events, I spoke, at least in part, on the value of good documentation. And at each one I gave similar advice: Do not try to trick Medicare/Medicaid into paying a claim, even one you believe it should pay but won't if you document everything accurately.

     For examples of what not to do or say, I gave these (which come, unfortunately, from things I've actually heard over the years):

     "Don't say the patient walked to the stretcher, say the patient was assisted to the stretcher."

     "Don't say you found a patient sitting in their wheelchair, say you found them awaiting transport, because otherwise insurance won't pay."

     After every event at which I've spoken, I've had someone come up and say they've heard phrases remarkably similar to those at some point in their careers. One more time, for the record, let me tell you: Tricking insurance into paying a claim, even when you think it should be paid, is not the way to go. Tell the truth, the whole truth and nothing but the truth. If a claim you really believe should be paid is denied, appeal the denial and fight for your money, but do it honestly. That is the only sure way to keep the money in the long run. The one thing I've seen in common among every single ambulance service I've ever seen indicted is that they've been accused of not being completely accurate on their trip reports or claims.

     As a side note, I spent much of the last year dealing with Medicare overpayment cases, some of which were well into the seven-digit range. Most of these cases had the element of medical necessity at their core, and out of almost $8 million worth of claims, we lost less than $5,000. So don't be shy about fighting for your money—good claims can and should be paid.

Emergent Trips
     ALS is no longer a vehicle, it's a service. Gone are the days when you could bill for ALS just because an ALS-equipped truck showed up. Dispatching an ALS unit does not automatically mean ALS service should be provided. An ALS assessment should be based on the needs of the patient, not solely on the fact that ALS was dispatched. And most important, if you're inclined to tell your staff to routinely place people on monitors "so we can bill ALS," don't. This is the other statement I hear much too often, and it makes me cringe every time. I don't believe there's any loophole that allows you to argue that ALS can be billed when an ALS assessment is done even though no ALS assessment was needed. Doing this is a sure way to be on the losing end of an audit, or even accused of fraud.

     I know, or at least I hope, that the vast majority of our readers are not people who violate or bend the rules, even unintentionally. But ambulance services are in the news all too often regarding criminal or civil cases based on facts like I've set forth in this article. Late last year, an ambulance service owner in Texas was sentenced to eight years in prison and ordered to pay $2.7 million in restitution, and the owner of a company in California agreed to pay the government $6 million to settle the civil side of a False Claims Act case after he'd already been sentenced to nine years in a criminal case.

     If I do nothing more than bring these issues to your attention and keep one person from going down the wrong road, I'll be satisfied that my time writing this column was well spent. The best advice I can give you is to avoid even the appearance of impropriety. Do things right, do not cut corners or get creative, and help polish the EMS image—yours, and that of the entire community.

G. Christopher Kelly is an attorney practicing in Atlanta, GA. Chris focuses on federal laws and regulations as they relate to the healthcare industry and specifically to the ambulance industry. He also lectures and advises ambulance company clients across the U.S. Contact him at chris@emscltd.com.