Compliance

At our recent webinar, EMS Billing Compliance: Preventing Costly Documentation Mistakes, one topic that flooded the Q&A was crew signatures. 

“Is it a requirement for both crew members to sign the PCR or just a recommendation?” 

“Why would a crew member who isn’t the primary provider need to sign?” 

“We get push back because the one driving doesn’t know exactly what the other provider did in the back.” 

The answer to the first question is no, in most states it isn’t a requirement to have both crew members sign the patient care report (PCR). But it is strongly recommended as a legal and compliance best practice. Let’s dive into why, which will answer the rest of the questions. 

Fully Staffed Ambulance

To be considered a valid transport, the EMS agency must be licensed with the state to provide services, the ambulance needs to have the appropriate supplies, and it needs to be fully staffed. Federal regulations require an ambulance to be staffed by at least two people who meet the requirements of state and local laws where the services are being furnished. In other words, to be a valid transport, an ambulance must be staffed by two or more crew members. 

Ambulance agencies submit claims to most payers electronically, so do not have to submit PCRs, documentation, or other proof of transport in order to be paid. However, you are required to maintain all records of the transport including proof of compliance with vehicle and staff licensure and certification requirements which auditors, investigators, or oversight agencies can request at any time. 

Authenticating the Record

Medicare requires that anyone responsible for providing care or services to beneficiaries be identifiable. If an auditor has concerns about the legitimacy of the documentation they can require verification of signatures, seek an attestation from providers who did not sign, or, if neither can be obtained, deny the claim. 

Because ambulance transport requires at least two crew members, if only one crew member signs the PCR there is no proof the other crew member was present other than their name being entered on the report. Auditors can, and have, required agencies to obtain attestation statements from crew members who didn’t sign originally for each claim where there was only one signature. If the attestation statement couldn’t be obtained from the second crew member, the claim was denied.  

Audits typically happen years after the transport took place, so in the event you were required to obtain attestation statements, the crew members who didn’t sign the PCR may no longer be employed by your agency. Those otherwise valid claims would be denied because both crew members didn’t sign at the time of transport. 

Drivers and Secondary Providers 

The guidance on signing medical records says even in cases where two individuals are in the same group, one shouldn’t sign for the other in medical records or attestation statements. This supports the idea that second or additional crew members, even when they aren’t the primary provider, should sign the PCR. When the primary provider signs they are signing as the author of the report and attesting to the care they personally provided, not what was done by the other crew member(s).  The signature of the second crew member provides proof of their presence during the transport and attests to the care or services they personally provided to the patient whether it was an assessment, a single intervention, driving the ambulance, or being present to fulfill staffing requirements. 

Compliant and complete EMS patient care reports should include space for all crew members to be properly identified with their name, credentials, role, and signature. 

Whether it’s confusion over medical necessity, proper PCR documentation, or signature protocol, EMS agencies regularly struggle with the complexities of documentation. More importantly, crews aren’t always trained on the importance of narratives, which can have downstream impacts on both the patient and the agency.  

In our latest webinar, Digitech Head of Compliance Amanda Stark sat down with EMS Director Jim Duren of the Palo Alto, California Fire Department to talk about common documentation challenges, best practices, and the importance of building a culture where prioritizing quality documentation is the norm.

Quality documentation is part of patient care 

One of the key points made during the discussion was that patient narratives represent far more than obligatory paperwork. They can have a direct effect on whether a transport is reimbursed, and whether a patient gets unnecessarily charged. 

“When we think not only from a billing perspective, but from a patient care perspective, part of taking care of that patient is not sticking them with a bill that they don’t deserve,” said Amanda. “Tying documentation into patient care is something that doesn’t always get pulled into this conversation and probably should be.” 

“The quality of your documentation reflects the quality of patient care that you provided. It’s your calling card in a sense,” agreed Jim. “So even if you did a wonderful job, if you just wrote a one- or two-liner and checked off a few boxes along the way, it’s not reflecting what you actually did for that patient.” 

Detailed narratives also provide legal protection 

In addition to providing an accurate account of care given to a patient, Amanda pointed out that strong narratives also provide vital information in the case of a legal dispute or litigation down the road.  

“While it’s true that documentation is the basis for any reimbursement for transport, it’s also the legal record of what occurred. If there was ever any dispute about what happened, whether it’s the clinical care involved, a crime, or a motor vehicle accident, they may need to refer back to the PCR as a legal document,” she said. “It’s a very important piece of information; not just the data fields, not just the demographics. It’s the narrative as well, the signatures, the entire piece.” 

While dropdown menus, checkboxes, and AI have improved efficiency in PCRs and helped expedite portions of run reporting, both speakers noted that something has been lost in the process. In his role as an expert witness, Jim sees this when reviewing a case, typically when there is bodily injury involved or some type of lawsuit. 

“One of the things I’ve seen over the years is that narratives went from a SOAP type report down to one or two sentences on the ePCR that reference, see the flowchart, followed county protocol, and so forth,” he said. “There are glaring gaps in patient care assessment. Was the patient critical? Did you take vital signs every five minutes? Do the vitals match your assessment? Did you clearly document any changes? All of that is good documentation and is part of the medical-legal record that can be pulled up sometime in the future.” 

In a police incident, he added, body cam footage becomes part of the equation as well. When that footage doesn’t represent clearly what is noted in documentation, there is a large gap in the incident record. Given that run records and narratives might be revisited three or five years down the road, after thousands more transports have occurred and memories have faded, it’s vital that details be captured thoroughly and accurately. 

Signatures are non-negotiable 

No discussion on EMS documentation would be complete without including patient signatures. Not an after thought or an optional ask—patient signatures are a critical part of EMS documentation, ensuring the record meets legal requirements, and the claim is eligible for reimbursement. 

Amanda stressed that no signatures should be completed by crew members or anyone else other than the patient just to check the box.  

“I think some of it is a lack of understanding; a crew member thinks I was told I have to get a signature and if I don’t, I’m going to get in trouble. But committing fraud is a way bigger problem,” she said. “Knowing the rules but also understanding the ‘why’ behind them helps in those moments.” 

In addition to patient signatures, Jim said, adding that at his agency he stresses the importance of getting a witness signature when a patient refuses transport. “Someone watched and knows that you explained [the risks of refusing transport] to the patient, the patient understood it, and the patient signed that they understood it. They witnessed the whole process; that will help mitigate any litigation further down the road.” 

Creating a culture of communication 

Amanda and Jim agreed that for EMS agencies looking to implement and sustain strong documentation practices, leadership needs to set the tone. More than simply enforcing protocol, this includes explaining the importance of complete documentation including thorough narratives in terms of patient care and reimbursement, demonstrating how and when to capture a patient’s signature, and allowing for mistakes. 

“It can be a fast-paced environment moving from call to call—you may make a mistake and forget to write something down,” said Amanda. “You want to set high expectations and create an environment where everyone understands the importance of compliance and the importance of good documentation.  But you also want to allow room to be human and for accepting constructive criticism.”  

Jim emphasized that when it comes to creating that type of open and communicative environment in the department, captains have a vital role to play. 

“In our department, we hold to the idea that captains are responsible for their shift or their crew—and for the body of work that they do. So, our captains review the care reports of the providers on their crews,” he said. “Then, when we do run reviews, we bring in all the crews, captains, battalion chiefs, all units who were on scene. We put the run report up on a screen so everyone can see the work, and we go through it line by line to check it.” 

To catch more of Amanda and Jim’s insightful conversation, plus hear them answer questions from attendees, check out the webinar on demand. 

How many times have you read some version of this EMS narrative?

“Arrived on scene to find the patient sitting on the couch in no distress. Pt cc not feeling well since this morning. Patient assessed and all vitals WNL. Patient assisted to the stretcher and loaded on to the ambulance. Patient transported without incident. Care transferred to RN at receiving facility ER.” End of report.

There’s nothing wrong with it, but it is a problem. It’s so vague and generic it could apply to almost any transport. Sometimes narratives like this are written about a patient who has a minor illness and, at most, needed an appointment with their doctor. But sometimes they’re written about a patient who’s septic and requires immediate, life-saving care when they get to the hospital.

The problem is if most, or even some, of your agency’s documentation looks like this, your billing company, oversight authorities, auditors, and lawyers have no way to tell the difference. You’re likely leaving money on the table or at risk of having to pay the reimbursement you do receive back if you’re audited. And you’re exposing your agency to significant legal and compliance risk.

It’s common for crews to think they don’t need to say much in the narrative due to filling in the data fields on the ePCR. But the reality is the narrative should be the highlight of EMS documentation. It’s where other healthcare providers, auditors, and lawyers look first. And a high-quality, thorough narrative is the best way to ensure accurate, compliant billing.

Every transport is unique so there is no one-size-fits-all formula for narratives, even if you follow a system like CHART or SOAP. And you don’t need to, and shouldn’t, repeat every data field in the narrative.

But there are four things to always consider when drafting a narrative.

1. History of the Present Illness

Not the patient’s entire medical history, but the history relevant to the current transport. This should include either the mechanism of injury or the onset or change in symptoms. This is often missing from narratives but is critical for determining appropriate billing.

2. Assessment of the Patient

Include what exactly was assessed and the findings. Such as the patient’s presentation including if anything was different than normal, external factors impacting the patient’s condition, and relevant symptoms and pertinent negatives. If the patient is complaining of pain, a pain scale and a description of the pain should be documented. And if the patient is injured, the injury should be described.

3. Explanations

If medications were given or interventions were performed, they should be explained. Conversely if an intervention was withheld or abnormal vitals were not addressed that should also be explained. Don’t expect readers to make assumptions or connect the dots themselves, all clinical decisions should be explained in the narrative.

4. Make it a Story

Think of what you would say if you were telling someone the story of the transport. If you’d include a detail or piece of information, it should go in the narrative. If you’d leave it out because it wasn’t relevant to the particular transport, even if it’s something you always do, you can probably skip it in the narrative. And don’t make the reader track down crucial pieces of information by referring them to other parts of the report, i.e. “see tabs” or “as above”.

Narratives shouldn’t be so routine that each one sounds the same. And they definitely shouldn’t be treated as an afterthought. Emphasizing the importance of detailed, specific narratives for each transport will improve your reimbursement, reduce your compliance risk, and help shield your agency from overpayment demands and penalties in the future.

For more insights on how to optimize your compliance documentation, join us for our next webinar:

📣 EMS Billing Compliance: Preventing Costly Documentation Mistakes
📆 Tuesday, June 23rd at 1:00 PM EST
👉 Register Here

 

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.