Show Me the Money!

No doubt, you are being asked to do more with less these days. That means, as an EMS manager, you need to do much better at raising the funds your organization requires to survive. How? Number one, by thinking more creatively about the relationship your service has with the community. EMS customers, emergency response stakeholders, and public and private funding sources are all intertwined. How robust those relationships are affects how forthcoming the money is. Like you, individual patients, budget-conscious legislators and civic-minded business entities are all penny-pinching. When it comes to getting the money you need to serve them well, fundraising is all about relationship-building.

     Obviously, if yours is an organization that bills for 9-1-1 response and/or medical transport, then reimbursements are your most basic source of funding. Therefore, you need to be as effective as you can be with initial billing and follow-on collections in order to see a quick and full return. Are you keeping up with Medicare and Medicaid regulations? Are you paying attention to insurance claims that are getting kicked back? Are you billing often enough?

     Beyond that, are you thinking broadly enough about the expertise within your ranks? What other kinds of services are you--or should you be--offering, for which you can charge real money? Things like CPR and injury prevention training in your community, and other preparedness-type activities aimed at business or educational groups, can provide a revenue stream to your service if you've developed the market by building the relationships.

     As much as community leaders are paying lip service to the health, welfare and safety of their constituency, your organization is poised to raise the public's awareness of the necessary costs and value-added benefits of a healthy EMS system. When you're successful in that regard, you also improve the public's willingness to put their money where their mouths are.

     You may not realize that for special costs and one-time upgrades, there are numerous assistance programs out there. Are you current with what grants are available to your type of service? Equally important, do you have the right folks--those with know-how as well as know-who--applying for them?

Marketing and Public Relations
     Marketing and PR are your frontline strategies to increasing revenues, from grants to reimbursements, for public and private services alike. While private-sector companies are well aware of the need to market their services, non-profit and municipal services have not been as comfortable with the skill set required. The idea of "sales"--marketing's practical twin--is not always a natural fit with the provisions of emergency healthcare. However, says J.R. Henry, CEO of J.R. Henry Consulting Inc. and a paramedic for over 25 years--20 of those as executive director of Ross/West View Emergency Medical Services Authority in Pittsburgh, PA--"ambulance companies need to take a hard look at their marketing efforts. Most need to do a better job selling EMS to the public."

     Starting with the visibility issue-- "what we do for you"--and expanding that to promote the cost of readiness, marketing has to be in your mind whenever you communicate with stakeholders. Soliciting their priorities while promoting your services strengthens resources on both sides of the relationship. And it makes fundraising a natural activity, integral to your communications.

     Erik Gaull, PhD, adjunct assistant professor of Strategic Planning in the Department of EMS Medicine at The George Washington University in Washington, DC, and the former director of Operational Improvement for DC Mayor Tony Williams, cites the mayor's annual Citizens' Summits as a perfect example of relationship-building. Town hall forums such as these provide a venue for discussion about issues important to leaders and public alike. In DC, citizens can ask questions or speak out, with their opinions on the issues rated electronically.

     When EMS attends such public meetings, they are able to promote the importance of emergency response availability, explain the costs and price of emergency healthcare and get a clear commitment from the community all at once. When you develop this kind of back-and-forth, you might be surprised to find out, for example, suggests Gaull, that citizens are okay with a 10-minute response time once they understand how much a five-minute response costs. Conversely, once they understand the price they pay for slow responses, or equipment shortfalls, they are more willing to support funding requests.

     "Citizens make trade-offs all the time about spending money. Talk with them about what services they want and what taxes they'll pay to get them," he says.

     You can also find out what kinds of programs the public is interested in supporting and plant the seeds for additional services you can provide that they will pay for. Understanding each other's survival needs and financial burdens is the basis of a strong relationship. Not surprisingly, it is also the basis of getting funding.

     Beyond such meetings, relationships have to be built with community and business leaders, elected officials and the media in order to sell EMS and keep it in the forefront of their minds. The responsibility for making and maintaining these relationships might be taken by the director, chief or CEO of your organization, but everyone in the organization is responsible for their participation in them. The person responsible for raising funds, building revenue or making purchasing deals especially needs to develop relationships with those who have the resources you want to tap.

     Michael Paddock, CEO of the Rochester, NY-based Grants Office, a company that does grants development work "from soup to nuts" and also posts grants information on the Web, says it very clearly: "Grant-seeking is all about relationship-building. The better you are at building relationships, the more doors you're going to open."

     This is true no matter whether you are tapping organizations or legislators who could provide you with funds, private foundations who could provide you with equipment, or even patients (and their insurance companies) who owe you for services rendered. There is a strong correlation between how you market yourself and how you fare in the market.

Reimbursements
     It is important not to underestimate reimbursements when you think about "fundraising." After all, fees-for-service is standard business practice in every other industry. Perhaps it's EMS's unusual position between public health and public safety that causes so much confusion on this issue--healthcare in the United States is not generally free, but police and fire protection usually are. To confuse things even more, 9-1-1 response is free in some municipalities and from some departments, while others bill for it. This is where your relationship with stakeholders can run into snags: A condition of confusion will not help you get paid.

     Maggie Adams, managing consultant at PWW Consulting, Inc., the sister organization of the EMS law firm Page, Wolfberg & Wirth, notes that EMS agencies are usually effective in getting a bill out the door; however, collecting on the debt has not been the industry's strong suit, largely because of its long history of commitment to service. Encountering neediness in the field can make it hard to ask for money. "But, you need to remember," she says, "without money, you can't operate and continue to be there for your community."

     Making that point to leaders and the public well and often is a big part of your relationship-building responsibility. Simply, it is difficult to successfully bill someone who does not expect to get a bill at all.

Billing
     The other part has to do with how well you understand the needs of your patient, both medical and financial, including what his third-party payers need to know to help him pay your bill. That means getting the information you need to create what's known as a "good" bill. A "good bill is a compliant bill," says Adams, which means writing patient care reports that can be easily translated into billing codes.

     The accuracy and detail in a standard PCR can determine whether your patient's insurance gets billed properly and whether you get paid. This document is what ultimately connects the call to the payment. Henry explains: "When the field crews submit their PCRs--if they're documented properly--the billing staff or billing company interprets that data, codes it and then submits it to Medicare, Medicaid or other insurance companies."

     In a highly regulated billing environment such as we have, Adams says, "The better the documentation on the trip report, the better document the billing department will have. They have to ensure that what's documented meets the standards of medical necessity. You need a compliant document in order to create a compliant bill."

     Ambulance companies can find keeping up with these regulations daunting. Henry says he recently found $200,000 worth of mileage that hadn't been billed. "I have conducted coding and compliance audits for hundreds of ambulance companies across the country and almost every time I find unbilled revenue," he says. Ongoing training and even a periodic coding and compliance audit will help finance managers create compliant documentation forms to prevent underbilling.

     Furthermore, there is nothing wrong with billing right away. Adams suggests sending frequent statements to patients as part of your billing routine--at 16, 30, 45 and 60 days, rather than only once a month. You can allow patients to make payment arrangements once they respond.

Collections
     Unpaid claims from Medicare, Medicaid and insurance companies are often overlooked. Adams recommends that smaller services set aside time each week to follow up on all unpaid bills. In addition to tardy patient response, there are often problems with Medicare, Medicaid and commercial payers. You might even need to resubmit claims for any number of reasons, including insufficient information. Often claims simply get lost. "Don't wait for them to get back to you. The older a claim is, the harder it is to straighten out and get paid," she says.

     Every insurer works differently and each state has its own "prompt pay provision," which says how quickly insurers must pay, but generally speaking, claims can be followed up on after 30-60 days.

     How smoothly this goes depends on how much time you've put into developing a relationship with the payer company and how well you understand what they allow. You may wish it weren't so, but strangers are much more likely to lose your paperwork or reject your codes than someone who knows you or your accounting personnel. This means you aim for consistency--in your documentation and your collections schedule, as well as with your personnel. That is, assign one person to follow up on these calls and one contact person at the payer company with whom your staff regularly deals.

     When these relationships are strong, a simple phone call can often straighten out inadvertent errors or omissions. When your payer knows they can expect good documentation from you, occasional problems don't tend to snowball. Often the claim just needs more information--here's where your trip documentation comes in.

     For more information about reimbursements and collections or for coding and compliance training opportunities, contact J.R. Henry through www.emsconsult.org, or Maggie Adams at madams@pwwconsult.com.

Grants and Foundations
     There are grants for equipment, grants for infrastructure, grants for staffing and grants to match other grants. There are big, ambitious ongoing grants, and small one-time gifts to help get you through a rough patch. One of the most helpful resources you will find for locating grant programs is the 160-page booklet Funding Alternatives for Fire and Emergency Services, available without charge from FEMA. Inside are federal and state sources of funding, as well as ideas and examples of innovative ways departments around the country are raising money through their own marketing efforts. Download it directly at www.usfa.fema.gov/downloads/pdf/publications/fa-141.pdf or write them at Funding Alternatives Project Officer, USFA, 16825 S. Seton Ave., Emmitsburg, MD 21727.

Homeland Security Grants
     According to Paddock, whose Grants Office company works with government, non-profit organizations and private-sector partners to help identify appropriate grant programs that support specific projects, the Department of Homeland Security (DHS) has changed the way it dispenses its funds. Early problems with politics, controversial distributions and hard-to-meet deadline schedules that got in the way of the proper disbursement of funds have largely been fixed, he says. While much of the money allocated for DHS in 2003 and 2004 has yet to be distributed, efforts by Homeland Security Committee Chair Rep. Chris Cox (R-CA) have addressed many of the issues that created those problems.

     "Now it's corrected about three-quarters of the way," says Paddock. "The new application process is 'quasi-competitive.' Every state is still guaranteed a certain amount of DHS funding--0.75% of the total, which amounts to about $4 million per state--but above that, every dollar that DHS [sends to the states] now must be based on what's called 'risk and need,' where risk is determined largely at the federal level--and I don't mind saying through a kind of murky algorithm of intelligence information."

     Furthermore, "the states are now required to justify the need part of it through a new application process called Investment Justification."

     Investment Justification means applicants must justify their projects alongside DHS standards such as are spelled out in the National Preparedness Goals and the Interim National Infrastructure Preparedness Plan.

     Here's how it works: Each state is allowed to submit up to 15 investments, or projects. And each pre-identified major metropolitan area can also submit an additional 15 investments within homeland preparedness parameters. Agencies can apply to their state or municipality as one of those investments for projects that fall into these parameters.

     "The point is," says Paddock, "before, EMS agencies had to wait and see what the states passed down. Now they have an opportunity to collaborate with each other, take a regional approach that corresponds with national preparedness goals and submit their own broad-scale EMS project to their states--to be included in the state's justification to DHS, where it will be considered on a competitive basis with all the other applications. It's a new opportunity for EMS to get homeland security dollars that they haven't had before."

     The best way to find out about these is to go www.grants.gov.

Bioterrorism Grants
     There are two bioterrorism grants that also pass through the states and might be available to certain EMS departments. One, from the Department of Health and Human Services (DHHS), is called the HRSA (for Health Resources and Services Administration) Hospital Bioterrorism grant and the other is the CDC Public Health Bioterrorism Prevention grant from the Centers for Disease Control and Prevention. Both are sent to the states in the late spring and then made available to local hospitals and public health administrators in the late summer. For more, go to www.hrsa.gov/bioterrorism/; and www.bt.cdc.gov/planning/coopagreementaward/index.asp.

Assistance to Firefighters Grant (AFG)
     The most obvious source of DHS funding for EMS is the Assistance to Firefighters Grant Program (AFG). Also known as the FIRE Act Grant, the AFG program used to be open only to EMS organizations that were fire-based services. No more. Last year these funds--for operations, safety, vehicle and equipment acquisition and so on--became available to all non-profit EMS agencies.

     "I'll go on the record to say the Assistance to FireFighters Grant is the best-administered homeland security grant in the country," says Paddock. "It's competitive, it's transparent, there's a lot of technical assistance that surrounds it, and the narrative section is not too onerous--only about five pages. It's a great program."

     The SAFER Grants (Staffing for Adequate Fire and Emergency Response) is distributed by the same process and is earmarked for personnel rather than equipment, supplies or infrastructure. For more information on both grants, please visit www.firegrantsupport.com.

USDA Rural Development
     There is significant funding for rural first responders under the U.S. Department of Agriculture's Community Facilities grants program, says Paddock. Used to help build or upgrade rural facilities, including fire and rescue stations, these funds are also administered through the states.
For more information, contact your local USDA Rural Development office (www.rurdev.usda.gov/recd_map.html).

Commercial Equipment Direct Assistance Program (CEDAP)
     CEDAP funds provide commercial equipment to first responders and are available to those who were passed over by DHS's Urban Area Security Initiative (UASI), as EMS largely was. CEDAP is coordinated federally through the Memorial Institute for the Prevention of Terrorism's (MIPT) Responder Knowledge Base (RKB), which you can find at www. rkb.mipt.org.

     Mind you, CEDAP does not grant money; it provides equipment directly. "But if you qualify," says Paddock, "you can get exactly what you want. They actually have a CEDAP catalog, so it's almost like shopping. But you have to provide justification of need."

     The deadlines for many of these grants have already passed for this year, but never mind. It can take some time to develop a winning concept through which to apply for a grant. The concept starts by framing your need, then you propose the solution that the grant would fund, the outcomes of which are measurable. After that, Paddock says to expect to spend at least 30-60 hours writing the grant itself.

Private Foundations
     Foundation grants make up about $28 billion a year in total funding nationwide--not just for EMS. National foundations tend to focus on broad, systemic reform initiatives, which won't intersect much with local EMS needs. But local foundations, which tend to be responsive to local needs, are a good place to look, especially since they are "starting to expand their thinking to include emergency services in their eligibility requirements," says Paddock. "More and more EMS agencies are now able to get funding from local foundations where they wouldn't necessarily have been able to get funding before."

     Local foundations can come in handy in three main areas: small projects that don't rise to the level of state or federal funding (new uniforms, say); larger projects that are federally or state-funded but the funding is so focused that it doesn't cover costs for the whole project; and projects that have a matching requirement from the federal or state funding source. Local funding from foundations or businesses can fill in these gaps or provide a solid match.

Bringing It Home
     To get just about any grant, but especially the AFG grants, Paddock says you must identify the problem or need your service has and apply for the money to solve it.

     "People generally start off with a project like, 'We want to move to a new type of communication system.' Well, why do you want to do that?"

     Every grant application includes a narrative portion where you must justify your request. Paddock says to describe your situation in quantifiable terms such as: "We can't talk to the fire department with the communication system we have now." Then present your proposed project (in this example, the purchase of a new telecom system) as a reasonable remedy that addresses the need with a quantifiable solution.

     The importance of this approach in any grant application cannot be stressed enough. Grantors want to fund solutions.

     "You need to start with a good, solid need statement," says Paddock, "then the project should flow from there as a way of addressing that need or problem. The outcomes from the project must then relate back to the need, and improve your ability to respond or reduce barriers to response."

     In addition to the FEMA booklet (mentioned above), there are several ways to find grants that could help you. Information about federal grant programs can be found at www.grants.gov, which is administered by DHHS.

     Grantsoffice.com offers a subscription service that can put you in touch with both government and private foundation grants.

     The Foundation Center (www.fdncenter.com) offers an online directory where subscribers can get information on foundations only.

     Subscription services will run from around $25 to $50 a month for this and more information about applying for grants. Most local libraries also have local if not national grant sections--the reference librarian will be able to tell you how to navigate what's there.

     Once you've found your source, you need to get someone to write your grant who can articulate your vision in terms the grant reviewers are looking for. Paddock says it is increasingly important that someone who understands both the requirements of the grant, as well as the needs of the applicant compose the application.

     "Because your applications are going to be scored against other people's and you have to be able to articulate not only your need for the project, but also how your project fits in with national preparedness goals, for example, it's very important," he says.

     Grant writers are experts at understanding what funders want as well as how to articulate your project in a way that corresponds with the requirements of the funder. Many grants, including AFG grants, allow you to use a part of the funds retroactively for the grant writing.

     But what grant writers don't have is that all-important relationship with your funders that you should always be developing.

     "It depends on the grant," says Paddock, "but some depend almost exclusively on your relationship with your local Congressman, and others depend on your ability to articulate a justification that is going to score well with the reviewers of the particular grant program.

     "In general, though, grant seeking is all about relationship-building. The most successful agencies are those that are good at building relationships with their state and local leaders, as well as with elected officials at state and federal levels."