The Public Providers working with the PP-GEMT program were simply underpaid and no one noticed. There are a lot of funds that should be in the hands of the provider. DHCS Fee for Service (FFS) and the Managed Care programs simply failed to pay the PP-GEMT when Medicare was primary. Straight Medicare or Managed Care.
I don’t usually like to mention Sharp Ambulance Billing in a Blog as I like to keep it generic to our industry and not a sales pitch. But I will make an exception in this case. It seems only Sharp updated their system in a way to track the PP-GEMT payments for Emergency Base Charges over the Medicaid base and in the more important case, the Medicare base payments/allowable.
Due to the systems put in place, we were able to quickly see that for the Medi-Medi (dual) claims the PP-GEMT was not getting paid. Likewise, a smaller percent of Medicaid primary claims was also underpaid, enough to be significant funds missing.
However, almost every commercial system in use today tracks the average payment per run. Take a quick look at your California Medi-Medi (dual) report and see if your average per claims on a Medicare – Medicaid claim is over $1200 or significantly below that. I will venture a guess it is the latter as that was what we found with over 20 California Public EMS providers we discussed this issue with.
Good news is that it may not be lost revenue if you can convince DHCS you were underpaid and they need to correct this. Sharp has done this with all our providers – DHCS and the Managed care plans. However, be prepared for a lot of paperwork, custom Excel spreadsheets and a lot of meetings to get these funds.
Why is this important? It quite likely adds up to hundreds of thousands $$ yearly for smaller providers with a decent Medicare – Medicaid mix and millions of dollars for the medium-sized accounts and maybe tens of millions for the larger cities.
The math and process are simple. PP-GEMT for example pays $1168 for base charge only – basic emergency transport. Medicare allowable is maybe $500 in a specific area. And Medicare pays 80% of that and Managed care plans never more than that. PP-GEMT owes an extra $668 or more if Medicare only paid 80% of the allowable. But that was not being paid by DHCS.
Sharp brought this to the attention of DHCS almost 2 years ago. It took that long to determine whether it should be paid and was it being paid after Medicare. The answer was yes; it should be paid and no, our systems (DHCS) are not programmed to pay for it and we have not been paying for it. The process of correcting that and getting those funds has been a long and slow process. Involving a lot of DHCS meetings and Managed Care meetings and requests for specifics to be determined if payment was missed. Lists of underpaid and Excel sheets with detailed layouts per the different Managed care plans and FFS. Hopefully your billing software and billers can provide these, if not a lot of money is lost.
If you or your billing company are not doing this, I would highly suggest you should. Otherwise, a lot of taxpayer money is being left on the table.