Railroad Medicare Cites 32.6% Denial Rate in Widespread Review

Here we go again…

The Railroad Medicare program, administered by government contractor Palmetto Government Benefits Administrators (Palmetto GBA) has published the results of their latest “widespread review” of BLS Non-Emergency Transports.

Here we go again…

Railroad Medicare Cites 32.6% Denial Rate in Widespread Review

Continually, our industry is turning in dismal audit results with this contractor which is why continuously they conduct these reviews. Of 4,985 claims reviewed with HCPCS procedure code A0428, 1,623 claims were denied equating to a denial rate by dollars of 32.6%.

When are we going to get it?


The fact that there were 650 no response scenarios is downright inexcusable! That’s a cool 40% of the denials issued within the review.


Do we in the ambulance industry expect to remove ourselves from the CMS microscope if we can’t even take the time to respond with the records requested when summoned to participate in these reviews?

Responding is NOT optional. It’s not whether or not we feel like responding to the requesting contractor and by not doing so we will keep this blasted target on our backs for the foreseeable future.

When the request for records shows up in your mailbox, your billing office and your administration best be running around the office to pull those records and ship them out to the Medicare entity requesting them.

Are you kidding me?

Another 40% of the denials were attributed to insufficient documentation.

Are you kidding me?

Its 2017 people! Modern EMS has evolved so far in scope of practice and lifesaving technology and ability and yet we document like it’s 1967 and there is an abundance of Medicare dollars. No one cared in 1967 whether we billed for services or not and if we did we were but a small subsection of the Medicare payments that were issued.

Not so today.

In order to be reimbursed by Medicare and keep the money while surviving the audit trend unscathed your EMS agency MUST teach strict compliance and it must be a cultural thing to demand truthful, concise and complete run documentation.

A well-written Patient Care Report isn’t an option it’s a requirement.

The Railroad Medicare contractor cited these insufficiencies as being the most prevalent…

  • PCR incomplete/omitted
  • Wrong Date of Service/Wrong Patient
  • Documentation illegible (ever hear of ePCR programs? Huh?)
  • Lacked sufficient documentation to support medical necessity (like running nails over a chalkboard to us…grrrr….)
  • If required, a Physicians Certification Statement was omitted for the response to the request for review or it was incomplete.

The Importance of Signatures

Out of 1,623 denials, 130 of them were denied for a “non-confirming” signature scenario. Palmetto GBA listed the various types of in inadequacies…

  • Physician Certification Statements (PCSs) for repetitive non-emergency transports were not signed by an M.D. or D.O.
  • PCS not signed prior to a repetitive transport scenario
  • Transport was more than 60-days from the PCS signing
  • Illegible signatures with no printed ID of the signaturee
  • No credentials listed and/or an inappropriate person signed the PCS
  • Beneficiary/patient signature either was missing and/or not dated
  • When the patient was unable to sign, no representative signed in the patient’s place

Our billing office has preached the signature sermon over and over so much that we know our clients probably get tired of hearing from us. But, this review is proof positive that we cannot mess around with the requirement.

60 more…

Finally, 60 more claims were denied when Railroad Medicare’s review staff determined the trip was not reasonable or necessary.

We must inquire….where are all of your call intake staff members? Are they sleeping? Are they playing video games? Well they must be, because to take an unreasonable or non-Medically Necessary run in today’s environment is not making good use of anyone within your organization’s time or energy.

Be smart when doing call intake. Develop consistent questions you need to ask when the phone rings and someone is on the other end with a transport request.

Just because the wheels on the woo-woo bus are turning doesn’t mean that the cash will be flowing if we don’t do things right.

And…until we get it right….Railroad Medicare will conduct yet another review over the next 3 months?

So get it right!

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