Commercial Insurance Improper Use of the No Surprise Billing Act

Many insurance companies are purposely and improperly using the No Surprise Billing act and similar State acts to underpay ambulance companies and get away with it.

If your billing company and/or your internal billing is not paying attention to what private insurance companies are paying, what they are writing off– and worse–what they are telling their patient the new law allows them to do, you are allowing them to rip you off. You earned these payments and the insurance is paid by the patient for a plan that covers these fees for their patients.

This misuse of the laws, whether on purpose or by mistake is likely costing you money that you’ve earned. Trust me: they know they are doing it and are doing it by design. Many times I have seen a letter to a provider or to a patient quoting the law and leaving off the paragraph before that says this only applies to Emergency runs or this does not apply to Ambulance Transport. Do they really mistakenly leave off that section of the law?

What are they doing? They are sending a small payment or a smaller-than-billed contractual rate payment to private and government ambulance companies they are not contracted with.

Along with that, they then tell their patient they cannot be billed for the balance but only any copay or deductible they may have. THIS IS NOT THE LAW. Before the No Surprise Billing act, states like Colorado had a maximum of 3.5 times Medicare rates and they tried to send contractual payments. Florida has a law less exact that said no more than customary rates in the area and again the insurance companies tried to pay their contractual rates.

All this results in Insurance Companies trying to pay $350-$650 for a run where they may owe you $1300-$1500. Worse, they are telling their patients in writing that they do not have to pay the balance.

Fortunately the solution is simple, but also time-consuming and costly. But it is necessary if you want to collect all of your properly owed fees.

Step one: Make sure you check your EOB. There should not be write offs for commercial insurance, unless you are under contract with them.

Step two: Send a bill to the patient for the balance their insurance company should have paid but did not pay. If you want to save time and help your patient, include a document explaining why their insurance owes the money, what the law really is, and how they need to contact their insurance and get it properly paid so they are not stuck with the bill or sent to collections for non-payment. Provide the patient the tools to correct their insurance company.

At Sharp we also offer to get on a three-way conference call with the patient and their insurance to correct their insurance company’s misperception.

This is important if you do not want to leave hard earned money on the table. If you are not familiar with the No Surprise Billing act or the state laws in your area: get familiar with them. The insurance companies are misquoting these laws and sending threatening letters about how you cannot bill their patients and may be violating the law. These letters usually misquote or cherry pick aspects of the law, intentionally misleading your patient, and often leaving them frustrated and angry with their ambulance company, as a result.

This is an example of the statement they often leave off:

Federal Law
Main Statement in the Federal Law
Emergency and post-stabilization care and nonemergency care in in-network facilities; applies to fully insured and self-funded plans. Includes air ambulance services, but not ground ambulance services.

How you handle Medicare deductibles affects your bottom line

Why this is important

The way that you process claims that have a Medicare deductible is important.  If done right, it will improve overall collections.  A good billing company or department should know this simple trick if they want to make sure to maximize collections.

This technique will help you collect more and if you are neglecting to do this, you are definitely collecting less for your stakeholders.  It is one of those little things that when coupled with other processes combine to increase overall collections significantly–and it is easy to implement.

What problem are you solving with this process?

The patient-paid deductibles are not getting substantially paid. No matter how many invoices, statements, calls to a patient (or even sending the accounts to collections), the collection rate is low versus collecting that deductible from Medicare. Compounding this, these same deductibles are not paid by Medicaid programs in most states.  Medicaid is often the secondary payer to Medicare, leaving these deductibles uncollectable.  The deductible simply becomes lost revenue.   

But a simple change in billing process can assist in making sure the Medicare deductibles on Self Pay and Medicaid secondary claims do not show up on your billed transport.  

Simple solution – keep unpaid Medicare deductibles off of your bills  

How is this done?  First identify if the Medicare patient for this claim still has an unused deductible.   Next hold off on sending Medicare claims with unused deductibles until other payers’ claims for a Medicare payment have exhausted the deductible. This one technique will add significant revenue to your annual collections.  We also take advantage of this technique to ensure you get paid from programs like California’s QMB and other states’ programs, where Medicaid will not pay that deductible and you cannot bill the patient. We ensure you are not losing that revenue by waiting until another payer sends a bill exhausting the deductible.  By waiting, you will collect more. 

The next part of this technique will ensure minimum cash flow reduction. The second critical piece of this important technique is to recheck often to see if the deductible has been used.  At minimum, you should check two or more times a week. This provides for immediate billing once the deductible is exhausted.  

This is one in a series of simple changes to the billing process that can enhance your overall collections.  Look for future blog posts with other valuable techniques. 

Does the California GEMT QAF program help or hurt my company?

If you are a provider in California (or a state that is soon to implement a similar program), your first question about this program is – how will this effect my bottom line?

While this may seem to be a simple question, I get many of our providers asking me about the financial impact of this program. And as is often the case, the simple questions have simple answers, but we wonder– is there more to it?

The good news is: no, there is not more to it–it actually is a simple calculation. The one variable, of course, is how many runs you do that qualify for the fee-to-the-state by you and how many qualify for the extra revenue (meaning the extra payment from the state).

Fortunately, this is a very simple process, and I am assuming any good billing software can produce a payer mix report with the runs that qualify for the fee or the revenue. For example, in the California GEMT QAF program it is only Emergency Transport codes A0429, A0427, A0433, A0225 and A0434 that will qualify. The next step in generating the report is to produce this data for a specific time period (example below is a quarter since that is what the invoices are for).

In this simple report you can see a total of 210 runs that qualify.

This would result in fee of 210 * $32.30 (current rates), or a total of $6.783.

The income you should have been paid by Insurance Payers that are either Medicaid Fee for Service insurance or Straight Medicaid in our report would include Medicaid, and Medicaid HMOs. A total of 40 transports (7 and 33) for the Quarter. 40 * $220.80 (Current rate for the extra payment since the program started) or $8832 more.

Therefore your net gain in this quarter is $2079 ($8832 less $6783).

Roughly a $8,000 gain each year. From this example (see report below):

Hopefully, generating this report is simple in your system and you can check monthly, quarterly, or yearly to track and forecast the gain or loss from this program.

If you are unfamiliar with the terms GEMT QAF (or not in California or anywhere such a program is being considered), the below section provides some information on this type of program. This one is the California specific one:

CA GEMT QAF Program.

A short summary is this program provided a higher payment to those who provided emergency transports to Medicaid/Medi-CAL and Medicaid HMO patients. The extra payment was funded with a fee for each emergency run done.

A GEMT QAF Rate was calculated for FY 2020-21, in accordance with SB 523. The QAF is assessed on each qualified emergency medical transport, regardless of payer type. DHCS adjusted the QAF based on the transport data submitted for calendar year 2019 for emergency transport codes A0429, A0427, A0433, A0225, and A0434. The QAF rate in effect for FY 2020-21 will be assessed on ground emergency medical transports with dates of service beginning January 1, 2020 through December 31, 2020. The FY 2020-21 QAF rate amount is as follows:

FY 2020-21 QAF Rate: $32.30

Fee applies to all public and private, while most 911 territories have a larger mix of Emergent runs, they also have a better chance of getting higher paying commercial runs to help offset this. They also get a higher number of Medicaid runs, which bring the state reimbursement payment of $220.80 for all qualified Emergent runs.

Private payers without 911 territories use Emergent runs from a skilled nursing facility to an Emergency room visit and by nature of the age of the patient will end up with more Medicare which does not bring the reimbursement of $220. So, they pay the added fee of 32.30 without the added reimbursement.

These numbers are done quarterly with payment and can greatly affect the cash flow of small-to-midsize private ambulance companies.

Ambulance Billing – Accurate Forecasting


One of the trickiest things in forecasting revenue for ambulance billing is getting a methodology that combines the number of transports, the payer mix of the transports and the payer’s average time of payment. 

When your software and your database allow you to easily access and combine that data the result can be an accurate forecast for your P&L and your cash flow. Below I will review a couple of methods to produce an accurate forecast starting with the most simple and expanding into a more detailed and even more accurate method.

All the methods described below are from the Sharp Ambulance Billing dashboard and reporting tools, but should be available in any quality billing software on the market today. Unfortunately, I’ve worked with a lot of internal billing departments and external billing departments that fail to produce even the most basic forecast for their clients.

Many times the reports or forecasting tools that do produce something fail to take into account important factors that make a forecast accurate. Forecasting your cash flow may be less important for a government entity than it is for a private entity, but either should have a basic understanding of their revenue in order to determine they are getting all the revenue available and in a timely fashion.

Let us start with the most basic snapshot available on a good dashboard such as the one in Sharp Ambulance Billing that can provide you the ability to do a fairly easy estimate that is still fairly accurate.

The dashboard below provides some simple forecasting that for many companies is enough to estimate revenue for the near future.  The number of runs is tracked because months with more runs will most likely produce more revenue than those with less.   In this dashboard (graphs and bar charts not shown) you can quickly see how many runs were done in a month and the associated charges.  The charges will vary based on the mix of Level of Service.  

The next is payments received for the runs in that month.  This is not the month the payments were collected but rather what payments were made against the transports in that month.  Combine that with the costs for that month and you can track how profitable a month was.  

Also provided are write-offs for contractual payers such as Medicare, Medicaid and other commercial contracts. This is the part of the charges you cannot collect due to contractual obligations.  The data allows for a basic forecast in a month.  By using this data and the average per run or the average percent paid of the charges (over the last 6-12 months), you can produce a simple forecast.

 A forecast can be generated by using one of two simple calculations (or running a report that does it for you).  Either taking the charges times percent of charges normally paid, or by taking the average collection per run multiplied by the number of runs to get the current months estimated revenue.  Either provides a fairly quick and fairly accurate forecast of the revenue the chosen month will generate in total over time.  The second chart/report below can then expand that into the estimate of when that cash/revenue will arrive based on the history of how it arrived before.

Basic Dashboard Forecast Data

While the Dashboard above tells me April will generate $476 K, the chart below shows me when that income was received, which changes based on payer mixes and their average payment times. And often there is a mix of secondary payers, self-pay deductibles, co-insurance and co-payments and/or slow paying insurance companies.  All those variables combine to cause payments to trickle in over time.   In the example below for April 2018 we collected a total so far of $476 K.  When it was collected is shown on the Cash Flow for DOS Month report, example below is   $84 K was collected before the end of the month of April, $293 K was collected before the end of May and $50 K collected before the end of June.  Meaning within 60 days of the end of April (or the month I am forecasting cash flow for) I received 81% of the cash that month would eventually generate.   Then the next 3 months produced another 9.1%.  The other 10% trickled in, some as late as Jan 2019. This could be patients on payment plans, difficult to collect insurance, hospice, workers compensation, VA and many other valid reasons these are not collected sooner.

 Regardless of the numbers and timing the forecasting process in its most simple forms are the same.  Number of runs multiplied by a  typical average payment per run (over time), and payments collected as percent of total charges (over time)  allows a fairly solid methods to predict an amount collected, or expected revenue from that months transports.  Combine that and the average collected percent per month from the chart below and you have a fairly accurate cash flow forecast of that revenue. Combined with previous months and future months you can accurately forecast a particular month’s cash receipts.

Below this chart I will address a way to make this kind of forecast even more accurate with the Sharp Ambulance Billing tools and hopefully tools you may have in your software.   

Date of Service cash collection

How do you improve on this method?  The key to understanding the best way to improve on this method is to understand where the inaccuracy of this method is.  One of the conditions that can change your forecast month-to-month is if you’re payer mix changes fairly significantly month-to-month.  A larger mix of lower self paid, no insurance accounts, or a larger mix of insurance such as Medicaid can often affect the amount of cash you will actually collect.

Another factor that changes monthly is often the mix of service level (ALS versus BLS) mix can raise or lower the forecast.  While the service level mix is reflected in the total charges for the month, it may affect the average per run in the forecast.

Therefore the next step in providing a more accurate forecast is a report that takes each run individually and looks at the previous history to create a very detailed calculation run by run.  That detail is then totaled into a summary of the data.  The information can be displayed the same as the previous forecast, but it does the calculations using detailed data not an overview of the past.

Run by run this more accurate and detail forecast adds current month (forecasted month) data and uses the history of the same type of run with the same payer to predict collections to the most accurate level possible.  

While Sharp has several methods to produce such a report they all have one thing in common – they take the actual payer and service level run by run and produce expected payment revenue.  

For example one of the more accurate ones that Sharp makes available uses the 6-9 month history of those payers to conclude how much should be expected to be collected.  Of course, you need to have 6-9 months of history to use this report.  Therefore, the first less accurate reports are usually a starting point until such history is available. 

These more accurate reports look at primary payers and secondary payers.   This process is unique to many reports we use for forecasting.  For example the collection rate from a Medicare primary and Blue Cross Secondary might be 100% of the Medicare allowable.  Whereas the collection rate of a Medicare Primary and Medicaid in states like California are limited to 80% of the Medicare allowable as Medicaid will pay zero and will not allow the patient to be billed the other 20%.

Then there is the Medicare Primary and Patient secondary.  That is where the historical data from a 6-9 month period might tell us a more accurate depiction, for example we only collected 92% of that allowable.  If reduced from 100% because too many patients are difficult to collect their co-pays from if at all.

While there are many other ways to make reports more and more accurate they all require historical data, and sophisticated software.   Even with the tools it takes someone with the expertise and the ability to understand the software tools and how that data is created to insure it is accurate.

Also can that software and data produce accurate reports customized to the uniqueness of each ambulance company? Many times I have found software that could possibly produce these types of reports and information but the users were simply not capable of making the tool do that. That is where the expertise of your billers and people knowledgeable of the software’s database and reports can combine to make more accurate forecasts.

If you need this type of information today and are not getting it I would suggest finding a way.  Either find out how to use your software to produce that type of accurate reporting or begin to look for new software or even a new billing service.

It is most important that if you are reviewing reports for this information that you fully understand how that data you are looking at is calculated.  How a forecast is calculated must be known if you are going to rely on that forecast when making business decisions..  I often have asked a customer, how is that data calculated?  The same report can produce very different information across software, even something as simple as the average revenue per run.  One company report I reviewed only used the paid runs, which produced a significantly better result per run then including runs never paid.  But which was more useful when multiplying times run performed in a month.  The lower one was more accurate, because every month had a percent of unpaid runs, especially in the 911 business.  The first one was higher and might make your billing results look better, but it was not good data for the purpose of forecasting.

In running your business it is vital to have at least the simplest level of information for forecasting (that was discussed at the beginning of this article). It requires good data, good software and a very good understanding of the data and how the software uses it for reporting.  Are you capable of getting this from your software?  Are the users of your software capable of getting this information? 

Increase Your Ambulance Billing or EMS Billing Revenue by 10-15%

We have all heard (at least folks my age), “If I had a dime for every time____” and then fill in the blank. In my case If I had a dime for every time I heard “My ambulance billing service or my ambulance biller collects everything collectable and never leaves anything behind”, I would be rich. The fact is that in most cases, it is simply not true. What is worse is that management or accounting are not aware of that fact. They often have no ability to track anything other than that collection rates seem to be the same, or that the amount of cash collected is the same. But is “the same” good or bad??

The reason it is not true is actually fairly simple. That last 10 to 15% of the revenue in ambulance billing takes as much work as the first 85 to 90%. There are many reasons for this, but it usually boils down to the simple fact that denied claims, claims without proper insurance, claims without the right member IDs, claims that are difficult to collect from payers and other variances from the norm create an enormous amount of work.

These more difficult claims create the conflict in resourcing the billing department properly. In general, management or the billers themselves realize that they’ve processed almost 100% of the bills and have probably been paid by 90% of the claims. All this is likely filling up the work day, and often they don’t have time to properly work to completion those last 10 to 15%.

Everyone does some work on denials or rebilling claims or attempting to find proper insurance information, but almost everyone comes up short in that effort. It logically seems unproductive to increase your staffing level so much more to handle 10 or 15% of the transports. The natural inclination is to think I need to work 10% more to handle 10% more of the claims. But that 10 or 15% takes a significant amount more to work than the other claims and often is a significant lost revenue stream. That lost revenue stream in a private ambulance company can often be more than the profit margin. And even in government EMS billing departments, that is a significant amount of lost money for the organization.

How do you ensure that extra 10 to 15% is actually collected? The easy answer is to do the additional work required; however, that often takes too much time without the assistance of an excellent software product. That product would be developed in a way that allows you to easily identify the unpaid claims and more importantly automates a lot of the current manual processes to provide adequate time to the billing department to work them. Lastly, it must provide oversight for management.

During, the last seven or eight years , while upgrading billing systems to our more advanced software product, we often did a data conversion of the previous software’s data.

Almost always our more advanced reporting system would immediately identify 10-15% of the transports that, even though those claims had insurance, had never been paid. This was not the exception but the rule in doing close to 100 conversions.

The common theme was always surprise at the number of unpaid claims, and the “reason” the claims were never collected. The reasons included issues such as missing information on that claim and no time to rework them, and/or the previous system had not easily identified those claims.

Many times they had been billed properly but a payment or denial never occurred, and a simple rebilling would have quickly changed the status to paid. Obviously that is a problem with the insurance companies but we cannot fix that so better to deal with the problem.

Another common theme was that management or accounting departments had no way to actually audit the billing department and review such claims and request information as to why these claims were not paid. Without such oversight or ability to work in partnership with your billing department to manage this issue, there was simply no visibility of the need.

In discussing with management and/or accounting departments I often heard “our collection rates have been steady”. This comment to me made it clear they’d never been successful at collecting the last 10 to 15%, and again had no way of knowing they could have. The key is the ability to know what has happened with each and every bill in the system at any point in time, coupled with the knowledge as to what is being done to collect them. Sometime it is legitimate to give up and realize it is uncollectable. In that case however the transports should be flagged and coded as to why. Statistical tracking of that can also be useful.  But I would still add a caution, management should review even these to ensure they were truly not collectable. One person’s uncollectable can be collected with a different process. For example, claims flagged as uncollectable can often be rechecked for insurances like Medicaid, which may not always be found on the first eligibility check but can be found on a retry a few months later.

While this problem can always be solved with more resources in the billing department, a better more efficient way and more likely to be successful is through automation and review of the processes to rework these claims.

Areas of automation that make a difference and provide needed time for the billing department to work these more complex claims begins with automation of routine tasks. Some examples of such automation include: basics such as automatically importing electronic payment EOBs, using a system that moves denials from these electronic EOBs into a “bucket” to be reworked, using a system that identifies claims crossed over to another payer from Medicare (and some Medicaid systems) to track that additional payers payments, and many other processes that can be automated (too many to mention them all here).
More importantly is a simple but powerful reporting system that can easily identify all claims over a certain amount of days since being billed and the insurance has not made a payment.

Even better is a system that knows the typical time that each individual insurance company pays and alerts the billers to claims that are not paid in the timeframe, maybe even putting them in a “bucket” to be reworked.

That same reporting system should make it easy for the accounting department or the management team to quickly review the progress from the billing department. That review as a minimum should provide a process to take a particular date of service range and ensure that every bill has been worked to final conclusion.

This tool for billers and monitoring for management is especially critical in ambulance billing and EMS billing where the entire set of claims for a month payment cycle can be over a long stretch of months. Add in EMS challenges like auto accidents, workers compensation and less timely payments and tracking it needs to be easy and long term.

We all know about the lengthy process of patient payments (whether they were  uninsured or co-payments) that make that even more difficult to track, but a good system will be able to tell the difference and eventually track which ones of those patient pay accounts are truly uncollectable, and separate them from collectable accounts and accounts where insurance needs to be worked. Installment plans and other tools also need to be available.

Bottom line is that last 10 the 15% is a lot of work and often requires phone work and a variety of time-consuming steps, but that 10 to 15% of revenue is so important to every organization.

Are you sure you are getting everything you should be in your organization? Can your billing service or billing department assure you of that with detailed reporting? If not that should be a priority to ensure it is.

Privacy Requirements (HIPAA) in Ambulance Billing and EMS Billing

Recently our management team traveled to Las Vegas to update their Compliance and Privacy certifications. Upon their return we reviewed our processes and the privacy requirements for data and procedures. Most of the requirements involved a strong technical support team. After the meeting I wondered how well others in the industry implement these processes. In thinking back over the last seven years of working with providers of varying sizes it occurred to me that few really truly meet the requirements completely and took it to the highest level. Not everyone has their data protected both electronically and physically (locked doors/cabinets, employee and visitor entry logs, screen protectors, etc.).

Electronic safeguards are the ones I think people often do not address adequately, if at all. Items like database and file system encryption, email encryption or secure messaging, encrypting data in transit, role-based permissions with need to know access, secure remote backups, multiple backups with tested recovery plans, automatic session log-off or locking, remote wipe and theft protection. While nothing is full proof in this world today, making use of the many tools to protect your data and to eliminate or minimize the damage from a breach seems well worth the time.

I would think any provider that truly has a long term approach to their business would want to know what your vendor is doing to protect your data. I suggest that anyone with HIPAA data have this discussion with their vendors, especially their billing company.  And if you have your own technical resources, internal or external get them involved in the conversation also.  There is never too much protection, but there is a point where it is too little.


Paperless Ambulance Billing and EMS Billing

Thank goodness, gone are the days when all the ambulance billing paperwork had to be done by hand! At one time, every step of the process had to be entered and filed, resulting in endless amounts of paperwork. Needless to say, this was a tedious process, with much double-checking and manual verification required.

More and more, billing for EMS services is done electronically, and this has resulted in cost and labor savings. Getting to the next level in electronic billing means finding software or tweaking your billing system so that data entry is not duplicated, and information is entered once, or as needed.   And that means accurate transfer of data from the EMS Crew to the Billing Service.

From the initial 911 dispatch call, to the EPCR (Electronic Patient Care Record), to the billing system and maybe even to the hospital, why not utilize systems that can transfer and store important client records, medical information and signatures, allowing users to import information from system to system, and to enter only the new data, as required?

As we all know, for those working in the emergency medical field, documentation is key. When working with ambulance billing, the room for error is large. From the time a patient calls 911 or requests a basic transport, until the time a bill is sent, there are many opportunities for information to be missed, or entered incorrectly. By eliminating duplication of entry, the room for error is minimized, ensuring that all parties involved have access to complete and accurate records, and are only required to enter the new information that pertains to their task.

All aspects of the ambulance service can be handled electronically with the latest in ambulance billing technology. This system allows for data to be entered into the system one time, and then it is accessed by all parties electronically, saving on time and labor costs. Instead of clerks re-entering data from forms filled out by E.M.T.’s, they simply add any new information to an existing file. This will save on paper and clutter by eliminating paper forms and unneeded filing cabinets.  Many of the best EPCR systems also automate the sending of documents gathered in the field to the Ambulance Billing and EMS Billing services. The latest software in ambulance billing also features a very handy pop-up window so that all relevant data can be viewed during entry. In this way, the biller entering data can view the narrative from the E.M.T. personnel and find the pertinent information needed to complete the ticket for billing purposes.

Another great feature that will save on paper storage clutter is the ability to store EOBs (Explanation of benefits – Payment information) that are received electronically,  or even paper documents that you receive by scanning them into the system, thus allowing them to be sent along to the appropriate parties. Even checks received from patients and checks from insurance companies and their EOBs can now be stored with each transport or Bill and retrieved at the press of a key.  The best systems will take you from the transport entered, to the page of the EOB in one mouse click or enter key. All stored electronically along with the ticket and patient data for safe record keeping.

The ability to connect related documents is also important during the ambulance billing cycle. An example of this is to attach a copy of the EOB to the bill that comes in from the insurance company. In this way, with one simple click, users can view the explanation that goes with each ticket.

Another way to improve your system is ensure that patient information, such as medical history, medical conditions and any other pertinent data, does not have to be re-entered for multiple ambulance trips by the same client. A good system will ensure that all relevant data for the patient is stored is handy and accessible every time the patient is picked up. In this way, care decisions at the EPCR level are based on the most current and thorough information.

Storing your records electronically can save you precious time by making all aspects of documentation easier and more accurate. A seamless system that goes from the initial dispatch call to the patient billing will help everyone involved work together and be informed.