Ambulance medical billing is always difficult to handle because it has to be in keeping with multiple regulatory requirements. These rules keep changing to ward off the threat posed by fraud billing. Staying up to date with the requirements is in itself a big challenge. Some common issues that need to be kept in mind while billing for ambulance services include:
- Medical Necessity
This is the most important compliance issue in ambulance medical billing. If the patient’s condition is such that any other transport cannot be used, then it is said there is a medical necessity for ambulance transportation. However, if the patient could be transported in say, a car or van, safely, regardless of the availability of such a vehicle, then, payment may not be made. It is imperative that proper documentation is maintained for every case and submitted when requested. A physician’s order for transportation is not proof of medical necessity, and absence of order is not tantamount to ‘no necessity’. All the program coverage conditions must be met so that payment can be made. The only problem is that the standards of medical necessity are not properly defined. A patient care report or PCR is the medical documentation that has to be prepared by the crew on service at the time.
All payers need the signature of the beneficiary to accept the assignment as well as for claim submission. If the patient’s ill health prevents them from signing, their representative needs to do it. The representative can be a person related to the patient or a legal guardian, one who provides the SSN on behalf of the patient, or a representative from the ambulance provider’s side or a person representing the agency assisting the patient, and so on.
An ambulance provider or their representative cannot request payment for services provided if the signature is missing unless – there is proper documentation to show that the patient was not in a condition to sign, and that there was nobody else to do on behalf. Most payers require a signed form before processing for claims, and not necessarily for accepting the transportation assignment.
- Advanced Life Support Billing
This is another important factor in ambulance medical billing compliance; if advanced life support systems, which cost more, are used in place of basic and available systems can be used, it could result in denial. ALS service level can be billed for conditions that the basic EMT in the jurisdiction is incapable of providing care to the patient. Ambulance medical billing services staff are up to date with the approved practice scope for EMTs in the jurisdiction, and the skills that mandate certification beyond that level. The application of the ALS assessment rule involves the greatest compliance risk, for different reasons like wrong interpretation or incorrect assessment.
Ambulance billing comes with its own set of complexities. An in-house team may not be able to handle it efficiently unless it has the right exposure. However, an ambulance medical billing services provider, has all the necessary expertise to guarantee full and timely reimbursements.