To Bill or Not to Bill?
Navigating Ground Ambulance Balance Billing State-by-State
By Chuck Humphrey, B.A., EMT-B, CADS*
Take a Peek!
This blog space is brought to you by the fine folks at Quick Med Claims (QMC). QMC is a national leader in EMS revenue cycle management (RCM). As a QMC retiree, I’ve graciously been afforded the privilege of periodically taking “peeks” behind the QMC billing curtain. It’s a window into the EMS billing world for both air and ground ambulance billing that is both intriguing and rewarding.
Today, as you continue to read, consider yourself invited to take that peek along with me. As you share a view into the behind-the-scenes of a multi-state billing focus, allow me to share a unique facet of today’s RCM world. The challenge we will focus on in the words to follow is the challenge of remaining compliant with the growing number of ground ambulance balance billing state statutes.
So, buckle up and come on along as I walk you through the challenges of keeping up with the changing billing landscape.
Enacted Legislation
QMC has begun the journey recognizing that the states of Texas, Washington, Maryland, Colorado, Arkansas, California, Delaware, Indiana, Louisiana, Maine, Mississippi, New Mexico, Ohio and Oklahoma all have enacted ground ambulance balance billing legislation. *
Given the size and scope of an EMS RCM-focused company as QMC, one can quickly see that remaining in compliance with fourteen sets of legislative initiatives driving actions taken by a diverse billing-office staff, is no small task.
It means, monitoring the rules for each state, developing procedural guidelines for following those rules, monitoring compliance and all-the-while maintaining accurate and compliant reimbursement for the ambulance service clients that QMC serves.
Doesn’t NSA Cover It?
Complicating this journey, for QMC, is the public’s now perception that the federal No Surprises Act blankets the nation and covers all balance billing practices. And here we land on our first misconception.
NSA does not apply to ground ambulance billing. In fact, it is the only nationwide healthcare modality that NSA does not apply to. All other healthcare providers and suppliers must adhere to the NSA guidelines, including air ambulance organizations and their billing offices. Ground ambulance billing was specifically excluded from the NSA provisions, at least for now. Of course, that may change in the years to come.
So, as for now, the ability to limit and control balance billing or what the public sometimes refers to as “surprise medical billing” falls to the individual state legislatures to either legislate to control the practice or to not weigh-in on the practice, as is the case for the 47 other states (and territories) that have not tackled this issue.
The Task at Hand
It’s laudable that QMC takes a focused compliance approach. Led by an extremely capable and dedicated Compliance Team of individuals, the team continually monitors and sets the tone for all billing actions on behalf of QMC’s clients, company-wide.
The task at hand, in recent months, has been to form a committee of individuals across multiple operations and leadership teams to develop a comprehensive ground balance billing compliance process which lays the foundation of responding to and remaining compliant with the individual state balance billing rules and regulations.
The process began with the committee’s internal development of a grid-like digital matrix containing the necessary information for optimally understanding the breadth and depth of how the individual rules dictate actions that can or cannot be undertaken when billing beyond the amounts reimbursed by insurance payers. After the state regulation has been carefully analyzed by the Compliance Department, the matrix is updated with bulleted breakdowns of key legislative requirements such as agency and insurance applicability, payment formulas, timelines, etc.
The committee then reviews the current balance billing standard operating procedures (SOPSs) to determine if they address the unique requirements of each state. When necessary, SOPs are updated and published and impacted staff are trained. Members of the committee also analyze whether payers are reimbursing in accordance with the regulations.
The Compliance Team chairs the committee but ensuring compliance with the regulations is truly a team effort across multiple departments of QMC. The Compliance Team will periodically audit QMC’s compliance with the regulations.
The committee continually monitors for changes in individual state mandates. The nationwide trend is a growing number of states adding legislation to “protect” their constituents from undue hardship they perceive is being placed upon the electorate when insurance non-participating ground ambulance transportation results in an unexpected out-of-pocket expense.
The Difficulty
So, what’s the stressors involved in such a process? Some of the state rules are very nuanced and can vary significantly state-to-state, insurance company payment methodologies can be inconsistent, and patients do not always understand how the state rules (or the federal NSA apply to their situation.
Unfortunately, EMS operations in its entirety are certainly misunderstood by the public and certainly (my opinion) misunderstood by many of our elected officials- federal, state and local. As we move into the eighth decade of what we consider modern EMS, those who make the rules see EMS as “stretcher fetchers” or “ambulance drivers” who are secondary in the pecking list of essential public servants. In fact, in most jurisdictions, EMS is not considered essential at all as evidenced by the mandated tax-support for fire and police sans support for EMS.
However, when the phone rings at the lawmaker’s district office with the stressed complaint of a voter, then the issue of “surprise billing” becomes a pain point and action is often taken to limit the amount to be collected to cover the cost of EMS with the stroke of a pen and a vote to pass legislation that is vague and often quite confusing.
Complicating matters for a company like QMC, is the vast amount of legislation that often is intended to include ground ambulance billing provisions but does not expressly point to how the legislation applies to ground ambulance.
Add to this complication factor, a lack of directed mandates for insurance payers to comply and a lack of follow-up on the part of legislators to hold insurance payers accountable to pay or even to understand how reimbursements are to be applied.
Many states carve out legislation to only apply to certain types of ambulance providers (municipal, versus non-profit, versus for-profit, for example). Some legislation applies only to 911 emergency transports while other states focus their legislation on non-emergency ambulance trips and how those transports are billed and balance billed.
Payment formulas are a mish-mash of if then, then that rules. For example, several states have mandated reimbursement fee schedule amounts that are based on a percentage of payment applied to the national Medicare ambulance fee schedule, using that tool as the floor with its annual Ambulance Inflation Factor (AIF) update in the calculation. However, in other states, the payment mandate also allows for municipal bodies to set their own fee schedules and approves for balance billing reimbursement to be based on those carve-outs while others ditch the concrete Medicare-based determination for vague statements such as “usual and customary” or “equal to in-network payment amounts.”
The roll-out to the public often then praises the initiative- “I voted to protect you, the citizen, from unnecessary surprise bills!” (Is anyone really surprised at out-of-pocket amounts in today’s healthcare environment?) It all sounds good on election day, but what the public doesn’t see is the vague communication that is disseminated to the insurance payer community and, definitely to the ground ambulance industry so all parties can adequately comply with the rules.
Deliberate Action!
And so, it has become incumbent on QMC as a protection to its clientele, that this very functional committee commit time and resources to deciphering, initiating, and monitoring all billing activity as a compliance failsafe on behalf of the EMS clients they serve.
The matrix is developed as a fluid, living document. The process that ensues from the information pulled from legislation’s interpretation is channeled into the development of definitive SOPs that are closely followed by billing operations staff members. Compliance is monitored intentionally using internal auditing processes which then dovetails in return to ongoing educational initiatives to ensure that all billing-process stakeholders are in full knowledge of balance billing allowances and prohibitions.
As such, QMC is confident that one of the greatest selling-points for the use of a competent EMS revenue cycle management partner is what goes on behind the day-to-day cashflow and patient care report interaction. It’s the intangibles such as this ground balance billing process that provides peace of mind to those who trust QMC’s abilities.
(*Author note- We purposely omitted Pennsylvania’s Act 84 of 2015 for the purposes of this blog, enacted as of 1/1/2016, allowed EMS agencies to “opt-in” to receive direct EMS reimbursement. However, due to a lack of reimbursement mandated fee schedule in the legislation, historically only two known PA EMS agencies opted in. The Pennsylvania legislature currently is considering a bill introduced with a more definitive balance billing mandate tied to a reimbursement fee schedule based on the national Medicare ambulance fee schedule.)
*Chuck Humphrey is an independent contractor who spent 25 years in the EMS revenue cycle management industry, prior to his retirement from Quick Med Claims. In addition to holding EMT credentials in Pennsylvania, he is also a Certified Ambulance Documentation Specialist via the National Academy of Ambulance Compliance. Humphrey is a periodic guest contributor to the QMC blog and podcast space.
