“Service Not Reasonable and Necessary”

Part II

Welcome back to Part II of our look at Palmetto GBA’s widespread review of ambulance services in the second quarter of fiscal year 2013.

You’ll recall that last week we really focused on Palmetto’s comments concerning signatures and how their presence of lack thereof influenced their decision to not allow 56.9 percent of the 3,571 claims reviewed.

Because of the size of the report’s findings, we told you we’d break down the report into two sections. Today, in Part II we’ll share with you some of their findings on the subject of “reasonable and necessary.”

“The documentation did not support…”

A total of 1,271 of the 3,571 claims reviewed were denied because Palmetto GBA found that the services were not “reasonable and necessary.”

In plain speak, reasonable and necessary is the CMS/Medicare phrase explaining that basically the trip had no merit for payment under the ambulance payment guidelines. In the eyes of the auditors for this project, the claims submitted for payment for these ambulance transports were not adequately supported by the documentation reviewed to paint a picture in words proving that “…the use of any other method of transportation was contraindicated.”

We think it’s very important to point out that Palmetto GBA makes a distinct statement noting that the “The documentation did not support the patient’s condition…”
Shame on us!

We can and must do a better job at documentation. A report like this makes our industry look extremely bad. Worse yet, these findings further fuel the growing trend for CMS to justify kicking up more stringent auditing measures. We have only ourselves to blame for this trend.

“Insufficient Documentation”

A full section in the synopsis of Palmetto’s findings focused on insufficient documentation.  A total of 280 of the denials were made when the auditors on this project found the following insufficiencies. We’ve lifted each reason straight from the Palmetto e-mail with our two-cents in italics.

No Physician Certification Statement (PCS) submitted and/or documentation submitted to support medical necessity.

You’re kidding me, right? If anyone in the industry doesn’t understand the need for a PCS (for non-emergencies) and adequate supporting documentation for all runs then maybe it’s time to find a new line of work. This is basic!

The PCS date was not within the appropriate time frame.

Folks, know the PCS rules. They’re easy to find and well-documented. Shame on us for missing something so simple.

The PCS was not signed by the appropriate health care professional.

Again, read the rules. It’s pretty clear who can and cannot sign a PCS and for what scenarios and it’s pretty easy to “weed” it out before you take the trip. We’ve blogged on this before, it’s nothing new.

No run sheet submitted as evidence the service was rendered.

Really? You’re audited and you can’t find or didn’t submit a run sheet to support your claim? Denial deserved!

Run sheet submitted is for another patient or with an incorrect date of service.

When responding to a request for records always have several pairs of eyes look over the documentation you are sending before you send it. If the dates of service or patient names are not correct on the original paperwork then how did the claim get past QA/QI to begin with? Pretty good place to start asking questions…

Missing crew members’ information and/or credentials.

This is a point that Enhanced has really focused on in our educational efforts. CMS and the MAC’s are placing a higher level of importance than ever before on the documenting of qualified crew members, including each crew member’s identifiable signature and level of training/credentials on the PCR.

Our Point

Go back and read what we’ve just written again and then read it a third time so it soaks in.

Our point…many of these denials did not have to happen. The error rate could have been so much better had the participants been able to prove their case using basic documentation best practices.

How do you prove your case that a trip is justified as reasonable and necessary?

It’s easy. Provide adequately, well-prepared written documentation and supporting evidence via properly-executed PCS forms to support the claims that you are submitting. The rules are clear and they haven’t changed drastically over several years. So why is it that a large number of us, in the business, don’t get it yet?
We’re killing ourselves!

Palmetto’s Guidance

Palmetto offered guidance on how to improve on the error rate. Here are some highlights…

When a bed confined beneficiary was transported, the record must clearly document that the beneficiary was unable to get up from bed without assistance, was unable to ambulate, and was unable to sit in a wheelchair before and after the ambulance trip (emphasis added).

When a beneficiary was transported because of the need to remain immobile due to the possibility of a fracture or a fracture that had not been set, the involved bone and the date and time of the fracture or injury must be clearly documented.

The documentation must be clear and concise (emphasis added). Palmetto GBA (Railroad Medicare) covers ambulance transportation only when transportation by any other means would endanger the patient’s health.

The trip record should ‘paint a picture’ of the patient’s condition at the time of transport.

Bed-confinement, by itself, is neither sufficient nor is it necessary to determine the coverage for Medicare ambulance benefits. It is simply one element of the beneficiary’s condition that may be taken into account when determining the medical necessity of an ambulance transport (emphasis added).

More to Come

Yet another review is coming. Palmetto’s already decided to conduct a follow-up in the third quarter, which now makes three quarters in a row they’ve felt the need to check up on us.

This is one of many reviews taking place. All we can suggest is that you remain prepared. If your service is a client, we’ve got your back. As you know, we regularly communicate with you when incoming Patient Care Reports are missing or lacking adequate information and/or required elements.

This blog is proof of our continual efforts to educate our clients regarding the steps to take to remain off the “radar screen.”

Now is the time to put policies and practices in place to insure your PCR’s can support valid claims to the insurance payers- especially when billing to Medicare and Medicaid.

Need Help?

Call us today. We’ve been able to make a difference for countless EMS organizations who rely on us thanks to our “fanatical” approach to compliance. Current clients can contact Client Services with questions concerning anything we covered today. You can reach them via email. or pick up the phone and call us. You can now even initiate “Live Chat” with a Client Services representative.

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