In most cases, EMS gets paid only when they transport someone to the ER. So, if EMS doesn’t transport someone, they cannot bill for the ambulance cost.

This is an all too familiar issue. As an EMS, you do this for a living (most of the time), so billing for your services in order to cover salaries, ambulance cost, and more is a must. But you can’t just not take a call because you have a hunch it won’t lead to a transport, right?

The problem is sometimes the general public doesn’t know when to call 911 and they would rather err on the side of caution, said Albert Davey, executive director for Narberth Ambulance near Philadelphia.

“You don’t call 911 because you know what to do,” he said. “You call because you don’t know what to do.”

Davey paints a familiar scenario.

A panicky husband calls 911 because his wife is running a high fever and appears extremely groggy. The husband gave his wife acetaminophen before the 911 call. The fever breaks just as EMS arrives at the scene.

Once the fever stabilizes, the wife becomes more coherent and refuses a trip to the ER. Call it a false alarm, but EMS cannot bill for the house call if she stays home.

“If it’s chest pain, it’s easy,” Davey said. In that case, EMS will rush a patient to an ER.

But not all medical emergencies are clear cut, which requires paramedics and EMTs to make some tough decisions.

Cost of doing business for no fee

“You assess someone in the first 15 minutes and have to determine if it’s a fever or if it’s sepsis,” Davey said, adding that fever and sepsis present similar symptoms and sepsis can be easily missed.

On a monthly basis, Narberth Ambulance fields from 700 to 900 calls to 911. Of those, about 550 to 600 result in a trip to the ER, Davey said.

About 25% of the calls do not require transport, he said, which means EMS eats the ambulance cost, Davey said. The bill is written off as debt.

However, sometimes EMS will catch a break on ambulance reimbursements. When EMS is dispatched for a car crash and paramedics determine minor injuries not needing hospital evaluation and no need for ER services, they can bill the insurance company for a portion of the fee, Davey said.

Ambulance cost reimbursement model pilot programs are under way

Consider the non-emergency ambulance transportation pilot program for reimbursement of ambulance cost.

Let’s say a patient calls 911 because they need a ride to their cardiologist’s office. Should EMS refuse the request? Policies are changing, and it could help EMS collect payments more easily.

Non-emergency ambulance transportation is sometimes covered for Medicare programs when patients meet certain criteria, according to U.S. Department of Health and Human Services’ Centers for Medicare & Medicaid Services (CMS).

The CMS document titled “Medicare Coverage of Ambulance Services,” states the following:

“In some cases, Medicare may cover limited, medically necessary, non-emergency ambulance transportation if your doctor writes an order stating that ambulance transportation is necessary due to your medical condition. Even if a situation isn’t an emergency, ambulance transportation may be medically necessary to get you to a hospital or other covered health facility.”

Medicare started beta testing a method for non-emergency transport by using a pre-approval prior authorization model.

Initial states chosen for the program were South Carolina, New Jersey and Pennsylvania, back in December 2014. The program later expanded to Delaware, District of Columbia, Maryland, North Carolina, Virginia and West Virginia.

The program known as “Prior Authorization Model for Repetitive, Scheduled Non‑Emergent Ambulance Transport,” will run until Dec. 1, 2019. CMS then will evaluate whether nationwide expansion makes sense.

The purpose of this type of program is to determine whether a new model can reduce costs while providing quality patient care, or improved access to care, Davey said. Pilot programs like these can help push the needle forward for policy change.

ET3 coming to town near you

On Feb. 14, CMS held a webinar on ET3, short for Emergency Triage, Treat and Transport. It’s a five-year pilot program designed to assess a person’s true medical need and get them to the right place, which may not be the ED. It also would reimburse the ambulance cost to transport the patient.

CMS will take requests for applications starting in summer 2019 to Medicare-enrolled ambulance suppliers.

Under the ET3 model, CMS would agree to pay participating ambulance suppliers to transport people under the following circumstances:

  1. Transport person to a hospital ED or different approved location.
  2. Transport person to alternative destination, like urgent care or a primary doctor’s office.
  3. Provide treatment in place with a qualified healthcare practitioner — on the scene or via telehealth.

Here’s the big question. Will ET3 prove beneficial for EMS personnel? Traditionally, the ED has been the ultimate determination of a patient’s care. The new model drastically shifts that responsibility.

“The idea is that it would move liability from hospital to the ambulance,” Davey said.

Translation: Under ET3, it would become the paramedic’s job to determine whether a person needs ER services, urgent care or possibly psychiatric screening.

Davey said he is keeping an open mind about ET3, though he cites a few challenges that need to be addressed, including what is optimal for paramedics. He reminds people to consider the conditions under which paramedics work.

“Paramedics don’t always have the advanced tools or training to make those kinds of medical decisions. Paramedics often make life-and-death decisions for a person lying unconscious on the floor of a second-floor apartment in a dimly-lit back bedroom,” Davey said.

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