Expert EMS Billing

Code Red for Compliance: EMS Billing Experts Warn of Mounting Risks

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As ambulance providers across the country face an ever-changing financial and regulatory landscape, industry experts warn EMS leaders not to overlook small documentation gaps and billing inconsistencies that can translate into significant risk. Industry experts say that even minor compliance variances can have major financial consequences, negatively impacting agencies and municipalities already managing tight budgets.  

At the same time, recent enforcement activity under the False Claims Act reflects the growing attention on EMS billing practices.  In recent years, federal enforcement activities directed at ambulance agencies have resulted in six-figure to multi-million-dollar penalties tied to issues such as questionable medical necessity, documentation inconsistencies, upcoding, and errors related to skilled nursing facility (SNF) consolidated billing. The pattern suggests that ambulance billing remains a priority area for state and federal oversight. 

Importance of Accurate Documentation 

Despite the severity of potential penalties, an increasing number of compliance issues originate not from intentional misconduct but from inadequate or incomplete documentation. Digitech’s experience reviewing documents across hundreds of agencies points to frequent gaps in core clinical reporting, such as incomplete documentation of patient presentation and assessments lacking critical detail. Inconsistent narratives, unexplained abnormal vital signs, and missing rationales for interventions further compound the problem. Even seemingly innocuous shortcuts like referencing previous notes rather than documenting findings fully can increase the likelihood of denied or incorrectly billed claims. 

In addition to exposing agencies to financial risk, incomplete or incorrect documentation can shift an additional burden onto patients. Missing signatures, unclear clinical justifications, or delayed paperwork frequently lead to denials, leaving patients responsible for ambulance bills despite meeting clinical criteria for transport. Even though spending a few extra minutes accurately documenting might feel like a burden to the patient in the moment, incomplete documentation puts undue burden on the patient after the encounter and ultimately tarnishes the agency’s reputation. 

Leadership and Compliance Culture 

As regulatory expectations expand, EMS leaders are being urged to implement strong internal controls and foster a culture centered on compliance. Effective strategies include regular documentation audits, consistent training, clearer operational expectations, and corrective action when needed. Leadership plays a critical role in shaping this culture, setting expectations by modeling how to manage risk responsibly.  

Leading agencies take this one step further, emphasizing doing the right thing over chasing perfection. This means encouraging staff to ask for guidance when uncertainty arises and to document situations honestly when ideal procedures can’t be followed. A culture of compliance is reinforced when leaders “walk the walk,” demonstrating accountability and supporting staff in making good-faith decisions, while addressing recurring issues constructively rather than punishing occasional lapses. This approach ensures that adherence to standards becomes part of everyday operations, rather than a checkbox exercise, and fosters an environment where staff feel empowered to act with integrity even in challenging situations. 

A Growing Priority for the EMS Sector 

The convergence of rising enforcement activity, increasing financial penalties, and persistent documentation challenges signal a decisive shift for the EMS industry. Compliance must be viewed as a core operational function that directly affects financial stability, patient outcomes, and organizational resilience. 

For more on this topic, catch an on-demand recording of our recent webinar hosted by Digitech in partnership with Fitch & Associates. The conversation between Digitech Head of Compliance Amanda Stark and Fitch & Associates Senior Partner Anthony Minge, Code Red for Compliance: EMS Billing Experts Warn of Mounting Risks can be found here.  

Lost in Translation: 5 Ways to Reduce Risk When Using AI in EMS Narratives

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Whether ChatGPT is your new best friend, you’re afraid the machines are going to take over the world, or you fall somewhere in between, there’s no denying that AI has become a permanent part of the conversation. In the EMS space, we’ve seen more agencies enabling the use of AI in writing ePCR narratives. While the efficiency of such a tool is attractive, there are factors EMS operators need to consider in order to avoid potential documentation issues or compliance concerns. In other words, AI is not a magic wand; it should be viewed with the same professional skepticism that would be applied to any advanced technology.

Here are five guidelines on how to benefit from AI tools, whose successful output depends first and foremost on the data it receives.

1. Complement the Data with Observations

It seems obvious, but despite its seemingly ‘natural’ ability to form detailed descriptions, AI can’t put information into a narrative that doesn’t exist elsewhere in the chart, so an AI generated narrative will almost never paint a thorough and complete picture of the patient’s condition and transport on its own.

Put another way, when you consider the data sections of the ePCR, there is typically no opportunity to include additional elements that make up a high-quality narrative. For example, using a combination of data sections, an EMS crew can document a patient’s pain level, where the pain is located, and possibly when it began; but not the nature of the pain, the type of pain, or if anything makes it better or worse. Data sections—from which AI draws input—don’t include what the patient said, or any statements from bystanders.

As such, AI can’t describe the events leading to the illness or injury, articulate findings by the crew, or offer a detailed assessment. Therefore, to fully paint a complete picture of the patient encounter, crews need to enhance AI-generated narratives with additional comments and observations based on their assessment and treatment of the patient.

2. Review Narratives for Relevance

AI is programmed to pull certain data and put it into a particular format, but it doesn’t have the ability to discern what information is relevant to the patient’s condition and transport. For example, if a patient has a significant medical history listed within the data, AI will include all of it in the narrative, which may or may not be relevant to the reason the patient is being transported on a particular date of service. When irrelevant information is included, it can clutter the narrative, making it longer and less helpful in terms of determining why the patient is being transported that day.

For this reason, crews should always review and edit AI-generated narratives to eliminate redundant or irrelevant information and produce a clean, accurate record.

3. Review Narratives for Accuracy

When it comes to AI, output is only as good as the input used to generate it.  Because AI generated narratives pull from the data sections of the ePCR, any errors, inconsistencies, or missing information in the chart will automatically be reflected in the narrative.

Relying solely on AI to write a narrative eliminates any potential chance to catch and correct an error. Human review is imperative to make sure every account is error-free.

For example, one common mistake we see in the field is a crew member selecting medication administration via IO instead of IV in the treatments section. When the provider is describing their actual experience of treating the patient in the narrative, they have a chance to correctly recount giving medication via IV. Careful proofreading and review by a human are essential to catch errors that would be missed when solely relying on AI.

4. Remember: Even AI Can Glitch

As we’ve said, AI isn’t magic—it’s technology. Even without data entry errors, any tech can generate significant errors on its own. We’ve seen cases where information in AI-generated narratives wasn’t consistent with the data fields; notably one narrative referred to a patient by different genders throughout the report. AI, like all technology, can have glitches that cause errors, triggering a ripple effect through the process.

As such, proofreading is essential to accurate documentation. That has always been true for humans writing narratives and it’s still true for AI generated narratives.

5. Safeguard Legality and Billing Compliance

Agencies are responsible for creating and maintaining complete and accurate documentation of every patient encounter, both as the patient’s medical record and for compliant claim submissions. As such, the repercussions of inaccuracy can be costly.  If there is missing, inaccurate, or false information in the narrative, “I used AI” won’t be a defense in a lawsuit, an audit, or a False Claims Act investigation.

We’ve seen agencies who have enabled AI with the best intentions, yet their documentation quality has decreased—in some cases, significantly. With poor quality documentation comes the downstream potential for   and increased compliance risk. This reiterates the need for human input and review when it comes to implementing AI tools.

The Bottom Line

Crews should not expect AI generated narratives to be faster or “done for them.” 

To mitigate risk, we recommend that if you choose to enable AI, you start by doing so for only a small subset of crew members first. Preferably, begin with those who find documentation challenging. Then, develop training for everyone based on what you discover during the trial period.

Most importantly, remember—and impart to your crew—that you cannot take a hands-off approach if you choose to enable AI. Like any new skill, it will require training, monitoring, and feedback.

Three Documentation Practices That Protect Your EMS Agency

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Thorough and complete documentation is the key to compliance for EMS agencies. Your crews might see it as routine paperwork. Auditors see it as evidence. Lawyers see it as lawsuit fodder. At Digitech, we see it as the foundation of compliance and the safeguard for your agency’s revenue.

Taking the time to monitor and improve documentation can maximize revenue now by ensuring your claims are billed timely and appropriately. Strong documentation also protects you in the future by avoiding or reducing overpayment demands if you are subjected to an audit or investigation.

Here are three ways to improve your documentation that won’t take much time but will make a big impact.

1. Verify Crew Signatures and Credentials

Having an appropriately staffed ambulance for the level of service provided is necessary for compliance. Ensure accurate credentials are populating on the ePCR for each crew member. It’s easy for credentials to drop off during software updates or other system changes, and what seems like a small glitch can turn into a major headache if not addressed.

For compliance bonus points, have all crew members sign the PCR. It’s not a requirement in all states, but it is a best practice. A signature authenticates any interventions performed by the crew member, provides proof they were present, and creates a stronger record. In fact, we have seen audits where the EMS agency was required to get attestation statements well after the fact from crew members who didn’t sign the PCR at the time.

The next one is simple, but it’s an area you don’t want to be tripped up.

2. Train Staff to Proofread

It won’t make you popular, but it will improve your documentation. When the author of the report takes a few minutes to proofread, they can catch and correct missing, inaccurate, or inconsistent details before they cause problems.

In the vitals and treatments sections, look for dropdown or checkbox errors (such as selecting SPO2 reading on oxygen vs. room air or medication administration via IV vs. IO), watch for vitals that don’t make sense, and inconsistencies between sections. In the narrative, check for misspellings, incomplete sentences, and contradictions within the narrative or with other parts of the chart.

Narratives that are auto generated or written with the assistance of AI are not immune from needing to be proofread. If anything, they require closer scrutiny to ensure accuracy and readability.

And finally, a strategy that that’s absolutely critical for compliance.

3. Obtain Valid Patient Signatures

A patient signature should be obtained for every transport unless the patient is physically or mentally incapable of signing. When a patient is incapable of signing, the crew must document the reason clearly and ensure that it is consistent with and supported by the rest of the documentation. 

Common but invalid reasons we often see documented as to why a patient couldn’t sign include transfer of care/patient receiving care in the ER and contamination. We recommend removing these as options for crews to select as they don’t actually pertain to a patient’s inability to sign.

Encourage crews to double-check they are in the correct section or tab before obtaining a signature so it populates in the correct place on the PCR. The only person who should sign in the area for the patient, sometimes referred to as section 1, is the patient. The authorized representative area, sometimes referred to as section 2, is where a family member, power of attorney, or sending facility staff member would sign if the patient is incapable. The final area, sometimes referred to as section 3, is where the crew member and the receiving facility representative sign if the patient is incapable.

Bottom Line

Documentation deserves the same attention as clinical skills. It is a broad topic that should regularly be discussed and evaluated with your crews. While these three areas are just part of what should be addressed, they are common trouble spots that we see regularly delay claim submission or raise potential compliance concerns. By consistently monitoring documentation practices and addressing issues as they arise, your agency can strengthen compliance, safeguard revenue, and prevent avoidable headaches.