Patient Advocacy Through Documentation

Most EMS providers enter the profession with the goal of helping people. They dedicate hours of lecture and practice time to honing the practical, clinical skills needed to care for patients. 

Unfortunately the same cannot always be said of documentation and billing education. A few hours may be dedicated to documentation and crafting a narrative, but often no real time is given to what happens after our clinical efforts conclude and the patient enters the billing and reimbursement phase of our services. Poor documentation will hurt the EMS provider called into court, but poor documentation will also hurt the patient if reimbursement is denied due to lack of information. Claims denied due to poor documentation may force a patient to:

• Call the ambulance provider to find out what information they require;
• Send the ambulance provider copies of insurance information;
• Complete HIPAA paperwork to get medical records;
• Call the insurance company to find out why a claim was denied;
• Fill out and return signature forms to the ambulance provider;
• Appeal the denied claim to an insurance review board;
• Wait for the hospital to fill out paperwork documenting medical necessity;
• Wait for the ambulance provider to get hospital records to supplement poor documentation; 
• Possibly repeat all these efforts for multiple insurance providers.

All these things must be done while dealing with outstanding collection notices. If appeal efforts are not successful, the patient is now responsible for the ambulance bill. Putting them in that environment is not conducive to healing. 

Often EMS providers may feel collecting demographic and financial information for the billing department is not their job. EMS field providers should always focus first on providing excellent-quality clinical care for patients, but a secondary function of field EMS care is indeed gathering financial and demographic data, as well as accurate and complete documentation of clinical care. Collecting this information not only helps the financial health of an EMS organization but also the health of patients. 

In the current state of low reimbursement for medical transport, every penny counts. If an EMS agency is not financially solvent, it will not be able to take care of any patients, and overall public health will suffer. Good documentation of financial information will not only help the billing department collect the appropriate fees from insurance providers, it will also decrease the amount of time to payment, since appeals and additional paperwork can be avoided.

CMS’ Medicare Benefit Policy Manual requires ambulance services to be medically necessary and reasonable before payment may be made.¹ Documentation is the key factor determining the reason for the transport and level of services provided (i.e., whether they are medically necessary and reasonable). EMS agencies must keep the documentation on file and provide it upon request for audit. Incomplete documentation may result in claims being denied immediately or returned after an audit shows improper documentation of these requirements. 

Patients are a complex mix of body, mind, and spirit. A holistic approach to recovery focuses on all aspects of the patient to facilitate health. For the patient’s body to properly heal, the mind and spirit must be in a calm state of well-being. Decreasing mental and physical stress after a medical condition or injury has been proven to help the healing process. In a study published in 2011, Ohio State’s Jean-Philippe Gouin and Janice Kiecolt-Glaser concluded, “Psychological stress can have a substantial and clinically relevant impact on wound repair.“² Their study goes on to note that poor healing increases risks for:

• Wound infections or complications;
• Longer hospital stays;
• Increases in patient discomfort;
• Slower return to activities of daily living.

Additionally, the studies noted by Gouin and Kiecolt-Glaser showed distress was a better predictor of wound healing outcomes than sociodemographic variables or medical status—this shows the significant effect stress has on healing. Stress can be beneficial to us in short-term survival circumstances,³ but chronic stress has been shown to have an increased effect on:

• Irritability;
• Anxiety;
• Depression;
• Alcohol or drug abuse. 

Immediate physiological effects include:

• Elevated blood pressure;
• Elevated heart rate with increased risk of stroke or heart attack;
• Increased respirations with exacerbation of asthma or emphysema;
• Increased risk of developing type 2 diabetes due to increased glucose production;
• Numerous digestive issues;
• Reproductive issues;
• Compromises to the immune system. 

EMS providers can contribute to patient health long after our initial care and transport by reducing patient stress through complete and accurate care documentation, collection of demographic and financial information, and a seamless billing process. The less financial burden we leave for our patients to worry about, the more they can focus on healing. 

Responding to Complaints

Imagine this scenario:

You respond to a teenage patient who was ice skating and has a possible ankle fracture. Mom is on scene with the patient, and you transport to the nearby pediatric hospital. You get a demographic information sheet from the hospital and use it to fill out your electronic care report. Mom and daughter are resting comfortably in the patient room, so you decide not to bother them to verify the information. Several months later Mom discovers when applying for a car loan that her credit score is bad due to an outstanding ambulance bill. Since you did not verify the information from the hospital, you did not know she’d moved since her last visit and had a new address and insurance carrier. The billing department had been sending the mail to her old address, and she was not aware they’d been trying to reach her for payment. Now she calls the service furious that no one asked for her basic info or the insurance card she’d been carrying in her purse during the ambulance transport and emergency visit. 

Not only is this scenario poor customer service to patients and families, it is negligent of our EMS duties. Healthcare consumers expect to be asked financial questions. EMS providers should never hesitate to ask demographic or financial questions after clinical care has been rendered and patient custody has been turned over to the receiving provider. Providers should reassure patients that billing information will have no effect on the care they receive. Patients should know that we want to make the process easy so they can focus on feeling better.    

Agencies should actively monitor when in the patient cycle complaints happen. Complaints regarding clinical care can escalate when balance-due statements are sent. Patients who get an unexpected bill, especially when they should have had insurance coverage for the service, can look for ways to criticize every aspect of patient care when challenging bills. This can lead to increased complaints about clinical care, even when the catalyst for the complaint is a billing issue. Often the billing process is adequate and the claim is paid appropriately, but the patient is unhappy about their actual coverage. Many patients don’t read the fine print and don’t know the details of their insurance policies until they need to use them. 

Ambulance service policies and procedures relating to complaints are important to provide a consistent response to every issue. A policy should clearly state who handles the incoming complaints, and this person should be familiar with both the clinical and billing processes. A clear investigation and response process must be outlined and followed for uniformity to protect the agency, providers, and patient. 

Complaint management should include a tiered response system relative to the severity of the issue. A simple conversation may be all that is indicated for some complaints, while a full review by the medical director and a review committee may be indicated for more involved issues. Just Culture is an excellent philosophy for outlining your investigation policies and practices. A strong agency culture can also help prevent many of these types of issues. Timely follow-up is essential to expedite the process and get the patient focused on healing. 

Quality, billing, and training departments should meet regularly and work together to identify billing and documentation trends through data collection. Evaluation of clinical complaints in conjunction with billing issues can help identify root causes and drive education for field care providers. Regular measurement of documentation compliance is helpful feedback for EMS field providers and can be even more effective when communicated in a way that points toward benefiting the overall care of the patient.

Training on patient advocacy through documentation should happen during initial training when a provider is hired. It should continue with a follow-up from the billing department to show how provider documentation affects the billing process before the conclusion of any probationary period. Regular follow-up and feedback on documentation compliance is necessary for continued skill reinforcement. 

Patients deserve our best clinical care for good outcomes. Their outcomes are also impacted by clinical and financial documentation. Our goal should be to send the patient a summary at the end of the billing cycle with all eligible outstanding amounts paid in full. Being a patient advocate includes making sure our documentation flows as seamlessly as possible through the billing and insurance processes. Taking financial worry off our patients can allow time to heal in a calm environment. 

References

1. Centers for Medicare & Medicaid Services. Medicare Benefit Policy Manual: Chapter 10—Ambulance Services, https://www.cms.gov/Regulations-and-Guidance/Guidance/Manuals/downloads/bp102c10.pdf. 

2. Gouin J-P, Kiecolt-Glaser JK. The impact of psychological stress on wound healing: Methods and mechanisms. Immunol Allergy Clin North Am, 2011 Feb; 31(1): 81–93. 

3. Pietrangelo A, Watson S. The Effects of Stress on Your Body. Healthline, https://www.healthline.com/health/stress/effects-on-body#1. 

Brooke Burton, NRP, is the quality director for Gold Cross Ambulance in Salt Lake City. Brooke has over 20 years of EMS experience working as a paramedic in rural to superurban environments and specializes in performance improvement. Brooke is a board member of the National EMS Management Association (NEMSMA) and recipient of the American Ambulance Association’s 2016 award for Best Quality Improvement Program. 

Sidebar: What Medicare Requires

10.2.1—Necessity for the Service (Rev. 1, 10-01-03), B3-2120.2.A, A3-3114.B, HO-236.2 

Medical necessity is established when the patient’s condition is such that use of any other method of transportation is contraindicated. In any case in which some means of transportation other than an ambulance could be used without endangering the individual’s health, whether or not such other transportation is actually available, no payment may be made for ambulance services. In all cases, the appropriate documentation must be kept on file and, upon request, presented to the A/B MAC (A) or (B). It is important to note that the presence (or absence) of a physician’s order for a transport by ambulance does not necessarily prove (or disprove) whether the transport was medically necessary. The ambulance service must meet all program coverage criteria in order for payment to be made.

In addition, the reason for the ambulance transport must be medically necessary. That is, the transport must be to obtain a Medicare covered service, or to return from such a service. 

10.2.2—Reasonableness of the Ambulance Trip (Rev. 103; issued: 2/20/09; effective date: 1/05/09; implementation date: 3/20/09) 

Under the [fee schedule] payment is made according to the level of medically necessary services actually furnished. That is, payment is based on the level of service furnished (provided they were medically necessary), not simply on the vehicle used. Even if a local government requires an ALS response for all calls, payment under the FS is made only for the level of service furnished, and then only when the service is medically necessary.