Documenting for Dollars

Training for EMS providers emphasizes the importance of documentation from both medical and legal standpoints. But the importance of documentation to both our own financial well-being and that of our employers is rarely mentioned. It is this aspect that ultimately affects us most, so why is it that we spend little or no time concentrating on the financial significance of our care forms?

Many of us look at our prehospital care report (PCR) as a vital part of our patient's permanent medical record. In reality, this is seldom the case. Our findings and treatments are relayed to the people who form the next link in continued care via a verbal report. Our patient care form is filed away and likely never reviewed by a medical professional actually rendering care to the patient, so who does look at our report and why?

In the event of litigation, an attorney or a paid medical consultant in the employ of an attorney will look at it. While you may not be personally held legally responsible for what you do as an employee, it has happened in the past and surely will happen again. Even if you aren't held legally responsible, you are affected when things go south. Any damages awarded have a financial impact upon your employer. Your employer's insurance rates may increase, leaving less capital with which to pay your salary and medical insurance, fund your benefit package, provide your continuing education, etc. Your employer's reputation as a quality provider is affected, possibly decreasing the number of calls received or opportunities for contractual arrangements.

Whether or not litigation is involved, a dozen or more non-medical personnel look at every care form you write.

These people are responsible for collecting the fees charged for the services supplied. A clear and concise patient care record is the most effective link between field personnel and billing staff, and the billing staff is the critical link between services rendered and payments received. If your documentation is lacking in information or legibility, their ability to collect is hampered. This further reduces the funds your employer has available to compensate you for the job you perform.

Payers also look at your documentation. If billing personnel are unable to gain a clear picture of the patient's condition based upon your report, the care form may be requested by Medicare, Medicaid or a commercial insurance company for review. If they can't read your record, can't understand it or even just find it incomplete, they can and often do refuse to pay for the service.

Necessary and Proving It

So what are Medicare, Medicaid and other insurance providers looking for when they review a care form? Medical necessity. Not only does the patient transport have to be medically necessary, your documentation has to prove it. If your documentation does not provide the proof needed to satisfy the insurance carrier, your employer may not even bill the claim. If your employer does bill it, the agency may have to refund the money later on. Medicare and other insurers can perform audits to find paid claims that should not have been paid. If the care report does not support the claims, they can recoup money already paid out, even if it resulted from an honest mistake. Sounds bad, right? To make it worse, they may take a sample of 100 reports, and if 10 of them happen to fail to support the charges, they don't just ask for the money back on those 10 patients, they ask for 10% of the money back that they paid during all the times relevant to the audit. That could be hundreds or even thousands of patients, and thousands or hundreds of thousands of dollars! It's what's called a statistically valid random sampling, and such audit techniques are often used by Medicare.

The one report you drop the ball on could result in a claim being denied, and that could turn into dozens. Do it right each and every time!

Documentation Tips

What can you do in your reports to improve the financial well-being of both you and your employer?

• Write Legibly: The most important thing you can do to improve collections is to write legible care forms. If the billing staff can't read your writing, erroneous entries will be made. If the patient's insurance carrier can't read your writing, it may reject the claim outright. If your handwriting is so horrendous that it can't be read, print your care forms in block letters.

• Don't Be Afraid to Ask: Medical necessity is the key issue in getting most claims for ambulance services paid. The definition of medical necessity has been set by Medicare, and most private insurers have adopted the Medicare rules and definitions when it comes to payment. However, even the Medicare program is not run universally. The program is administered by a different "carrier" (private insurance company) in each state, and each company may have unique policies on some issues (which means that an ambulance service operating in more than one state may have more than one set of rules to follow). If you don't know what the carrier in your state requires or what its policies or interpretations are, ask (or have your employer ask for you).

• Don't Make Assumptions: Just because you are tired or bored or think the patient's chief complaint is beneath your ability, don't assume the trip won't be considered medically necessary. Not every call is going to lend itself to making you a hero. In fact, the non-emergency transports you do most likely bring in more money than the emergencies. Once you've memorized the Federal Register and all the Program Memoranda from CMS, you can consider yourself a Medicare expert. Until such time, avoid using derogatory language and presumptuous statements about things with which you are less than familiar. The patient might meet you at the curb with her suitcase, but if the patient is left at home, or as the responsibility of family to get to the hospital, she might die from that 212/108 blood pressure. Insurance providers realize this and will pay the claim. Actively seek out things about each call that might qualify it as medically necessary, rather than looking for things you can tell the patient to convince her not to go.

• Be Accurate: Charting a history of CVA, bed confinement, etc., will not satisfy most carriers. They want to know the complications of the condition, and they aren't going to pay unless you tell them. Instead, chart the underlying effects that prohibit the patient from being transported by other means, e.g., bed confinement with lower-extremity contractures; hemiplegia from previous CVA; fractured left hip.

In cases of transports to other hospitals for higher levels of care, carriers want to know what services were unavailable. Was there no neurological or orthopedic care available? Were there no ICU beds open? Just because one hospital has more services than another doesn't mean the transferring facility isn't capable of treating the patient. Just because the patient wishes transport to the larger facility doesn't make the trip medically necessary.

• Be Complete and Thorough: If something is requested on your care form, chances are it's needed to satisfy a requirement of one or more insurance carriers. Fill it out! Medicare bases reimbursement on the zip codes of the pickup and dropoff locations. It requires multiple pickups of the same patient from the same zip code to be billed together, while pickups from different zip codes must be billed separately. Having a name, date of birth and Social Security number will often allow your employer to find insurance information you were unable to obtain at the time of transport. The number of drug administrations and/or types of equipment used in delivering patient care can drastically change the amount of the reimbursement, especially if your service is on a fee schedule. If your patient care record is completed in the prescribed manner of your employer, billing personnel will recognize these special circumstances and file the claim appropriately.

• Be Honest and Consistent: Make your statements as complete as possible. This will help avoid what might look like inconsistent statements later on. For example, if each statement made is as accurate and complete as possible, questions will not be asked about why you did not mention some physical condition in last week's report on the same patient. Was the condition there from the beginning? If your documentation is complete, you will be able to answer this question.

• Avoid Using General Statements: Avoid using vague diagnoses or standard statements for each patient you transport. For example, avoid the phrase bed-confined if you can better describe the patient as unable to ambulate or rise from bed due to spinal paralysis from T-3.

• Be Kind, Considerate and Courteous: Not every call will meet medical-necessity guidelines. These claims may be billable to the patient, who will be more likely to remit payment if you appeared to have a legitimate concern for his or her well-being. Hiring an agency to collect from patients you have offended costs your employer money. This same patient might later require ambulance transport for a condition that does meet medical necessity guidelines. If he or she has experienced, or heard of, an unpleasant circumstance involving your service, they are more likely to call one of your competitors or go in their own car. Either way, you have cost your employer and yourself money.

• Get the Required Documents Signed by Your Patient: You may not be able to bill a patient for some services unless you have them sign the Advanced Beneficiary Notice form prior to transport. Know when this is required (for services rendered when it would have been more efficient to bring the service to the patient instead of bringing the patient to the service, or when the service might be downgraded from air to ground or ALS to BLS), and get it signed when appropriate. Likewise, you should get your service's Notice of Privacy Policy signed before the transportation takes place, if that is medically appropriate given the condition of your patient. Also remember that sometimes you must have a claim denied by insurance in order to bill the patient directly. Even claims that are sent in to be denied must have good documentation, or else the patient may dispute the denial or even claim it was your fault the claim got denied in the first place.

• Educate Yourself: Ask your employer to provide training in medical necessity, billing requirements, legal issues, etc. Attend these sessions and be attentive. Utilize the wealth of information available on the Internet. You can find multiple sources using any search engine, including all the Program Memoranda promulgated by CMS.

Conclusion

There are some EMS providers who think that regardless of how a company does financially, it still requires the provider to function, and that function is to provide medical treatment, not fill out forms. So thought many EMS professionals who have seen their services cut or discontinued and now seek other employment. Is it possible their former employer would still be providing service if their documentation had been good enough to see higher collections? Absolutely! No matter how noble our intentions, the bottom line is that EMS is a business. And like any business, it can't function in the red. ?

Nothing contained in this article is intended to be construed as legal advice. For reliable legal opinions and information about the rules in your state, consult an attorney.