Expert EMS Billing

EMS Billing Archive

Ethical Partnerships With Third-Party EMS Vendors

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The business world is built upon relationships. Relationships are the building blocks of the partnerships and contracts that keep all businesses running.

EMS is no different. You can’t do it alone. From medical equipment to apparatus to outsourced billing, partnerships with third-party businesses are essential to EMS agencies. But if those relationships aren’t built upon an ethical foundation, neither party will truly thrive.

We recently covered this important issue in a webinar hosted by Pinnacle’s Webinar Series. Our Executive Director of Analytics and former Battalion Chief at Gwinnett County Fire and Emergency Services in Georgia, Mitchel Holder, was joined by Nathan Sweet, Director of EMS at Anderson County, Tennessee, to discuss forging ethical partnerships with third-party vendors. Watch the webinar for key strategies and food for thought on this important topic in EMS.

EMS Third Party Vendors Forging Ethical Partnerships

 

Here’s what you can expect to see:

  • What does an ethical relationship with a vendor look like?
  • How do you prepare to solicit a new vendor partner?
  • How do you establish ethical relationships with vendors?
  • What are the standards for ethical business relationships?
  • How do you assess a potential partner’s commitment to ethical behavior?
  • How does an ethical partner behave when something goes wrong?
  • What are the qualities of ethical partner relationships?

 

50 Questions to Ask on Your EMS Billing RFP

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Issuing an EMS billing RFP this year? Selecting the right partner for EMS billing is a crucial decision for every EMS organization that outsources billing services.

Determining the best fit can be daunting. Choose wrong, and it could have devastating consequences to revenue and reputation. Choose right, and you could develop a mutually beneficial relationship with a vendor that helps your agency flourish for decades to come.

Many agencies go through a request for proposal process to find a billing partner, either for convenience and assistance with the search or because they are required by their governing body. Our team here at Digitech is highly experienced in creating proposal responses to these RFPs; we’ve read more than we care to admit over the years. In doing so, we’ve identified a standard set of questions that we believe should be in your next EMS billing RFP, whether you’re considering outsourcing for the first time, you know your department needs a change, or you are seeking to determine if your current provider is still the best fit.

This list arms you with 50 questions in six major areas to include in your EMS billing RFP. Answers to these questions will give you a deep understanding of the proposing vendors so you can make an informed choice.

Want a printable checklist? —> click here

Company Overview

  1. How many years has your company been in business?
  2. How many years has your company provided third-party EMS billing services?
  3. Disclose any key business partners, subsidiaries, and/or contractor relationships.
  4. How many EMS billing clients do you have and what type are they (e.g. municipal, hospital-based, private)?
  5. How many EMS claims does your company bill annually?
  6. How many employees to you have dedicated to EMS billing services?
  7. Provide an organizational chart providing the roles and responsibilities of the employees who will manage and/or be assigned to perform services.
  8. How many offices do you have dedicated to providing EMS billing services? Where are these offices located?
  9. Provide information about your customer service policies and procedures, including escalation and issue resolution processes.
  10. Describe how your company is notified of changes in legislation and how that information will be incorporated into your systems and processes in a timely fashion.
  11. List any professional EMS associations that your company belongs to.
  12. Provide a list of all award protests that your company has filed in the last five years, including the reason for the protest and the outcome.
  13. Provide contact information, start date, annual transports, and a brief narrative covering implementation and services provided for three current EMS clients of similar size, complexity, and scope.

Compliance and Regulatory

  1. Does your company have a compliance plan that is updated regularly?
  2. Is a copy of your compliance plan available for inspection upon request?
  3. Has your company, its parent, or a subsidiary ever been investigated for suspected fraud and abuse by any department or agency within the federal or state government such as OIG, Medicare, Medicaid, CMS, or Recovery Audit Contractor?
  4. Has your company, its parent, or a subsidiary ever been required by a department or agency of the federal or any state government to follow a Corporate Integrity Agreement?
  5. Has there been an investigation where the final determination resulted in a client paying a fine or penalty due to coding and billing actions that were related in any way to your provision of services?
  6. Are you able to furnish evidence upon request that all current employees are not excluded from participation in state and federal healthcare programs?
  7. Please provide a brief description of your company’s quality or audit process.
  8. Is any auditing process provided by an external vendor or source? If yes, briefly describe these audits.

Technology and Security

  1. Is the EMS claims processing and billing system you use proprietary to your company or is it software developed by a third party?
  2. Provide a general overview of the billing and records management solution. Describe the billing software used, who owns it, who supports it, how many clients use it, and describe the process by which required programming changes are made.
  3. List any additional licenses that are necessary to fully operate all available aspects of the proposed billing software, including reporting software.
  4. What level of access will be provided into the billing system? Will it include full visibility into all actions, notes, documents, etc.?
  5. Does your system provide logging of all activities on a patient account for all dates of service, and do you provide access to these logs?
  6. How is patient information stored, and for how long is this data retained? Are these records retrievable by the client?
  7. Please provide a brief description of your business continuity plan or disaster recovery plan.
  8. Provide a detailed listing of all data breaches including volume of patients affected and current status.
  9. Provide evidence of at least three years of annual SOC 1 Type 2 audits.

Coding and Billing Process

  1. What is your preferred method for receiving ePCR information?
  2. Explain the format that the ePCR data will be uploaded into the billing software, and what fields will be included, e.g. patient demographics, insurance, guarantor, medical procedures performed, chief complaint, dispatched as, and found to be.
  3. Briefly describe the training process for a new coder that starts with your company.
  4. How are coding personnel audited?
  5. How are claims assigned to coders? Are specific coders or groups of coders assigned to certain clients?
  6. If there is not enough information to code the claim, what is the process for obtaining the necessary information?
  7. Please describe the circumstances in which a claim would be returned to a client.
  8. What is the typical length of time required to bill a claim once the necessary information is received?
  9. What is your standard invoicing process and timeline?
  10. Describe the appeals and review processes for denied claims and the process for limiting denied claims. Show your historical record of denials.
  11. Describe the cash posting process.
  12. Describe the refund process.
  13. Please describe your process, including the frequency, for providing documentation feedback to providers.

Implementation and Onboarding

  1. Describe the initial phases of this project, including a proposed implementation plan.
  2. Describe how you ensure that implementation and the transition to your system does not negatively impact the billing and collections processes for our organization.
  3. What resources will we need to provide during onboarding and implementation?
  4. Describe the support and training you provide during the onboarding process, and describe the ongoing support and training for our administrative personnel that you will provide once onboarding is complete.

Reporting

  1. Please provide sample of weekly or monthly client reports that are part of your standard client reporting process.
  2. How are requests for non-standard reports handled? Is there a cost for these types of reports? If so, how is pricing determined?
  3. Please include any additional information regarding your reports and the data analysis tools provided to your clients.

We hope this list helps you get started in your endeavor to create or revise an RFP related to your organization’s EMS billing and coding process.

Three Critical Questions About EMS Revenue and Performance

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Action is at the heart of EMS: making quick decisions in the heat of the moment that are often truly a matter of life and death.

In the field, the business maxim of “if you can’t measure it, you can’t manage it” doesn’t exactly apply. You don’t expect a medic to pull up an analytical dashboard between calls and begin crunching numbers.

And yet, data analysis plays a huge part – not only in improving patient care and outcomes, but crucially, in the performance of the entire EMS organization. It is critical to understand the available data about challenges, opportunities, and strategy in order to make the best decisions for your agency.

In this whitepaper, we focus on three critical questions for EMS billing. You can use these questions to guide your analysis and assessment of revenue collection performance of your billing department, billing vendor, or billing solution.

  1. How are you calculating collection percentage – and why?
  2. How are you analyzing collections per trip?
  3. How are you measuring efficiency?

Click here to keep reading or download the PDF.

Embracing Change: Writing the Next Page of Digitech’s Story

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Today marks a milestone for Digitech. We’ve finalized the merger between the R1 EMS business and Digitech that was announced earlier this year, and we are now moving forward with operations as a combined business under the Digitech name.

As a 36-year-old company, we’ve seen a lot of changes that have impacted our organization in one way or another: the shift from paper dispatch systems to CAD. The creation of NEMSIS. Changing EMS education standards and compliance requirements. Revisions to Medicare’s national ambulance fee schedules. The Affordable Care Act. Advancements in mobile integrated healthcare. The still-evolving response to the COVID-19 pandemic. While some of these occurrences have been more challenging to deal with than others, Digitech thrives on these kinds of changes. Constant adaptation to the continuously changing environment of EMS is at the heart of our success.

Now we embark on a unique milestone for Digitech. Throughout our history, we have added clients and even employees carefully and selectively. Our growth can be attributed largely to strong references and referrals, and we are proud of that strong reputation. Moving forward, we will continue to build upon the mission and vision that R1’s EMS division (formerly ADPI/Intermedix) and Digitech share: compliantly maximizing collections for customers through time-tested processes and powerful technology, keeping revenue flowing so EMS providers can focus on keeping their communities safe and healthy.

This shared dedication brings together two companies that have been competitors for a decade. As we continue under one metaphorical roof, we have a great opportunity to bring the best, most trustworthy ambulance billing services to even more Fire and EMS agencies across the country.

As one business, we bring a deep level of expertise to the marketplace. At Digitech, EMS billing is all we do. We are not part of a larger revenue cycle management company, and we do not have other divisions that focus on different lines of business such as physician billing. This allows us to specialize like no other company can. Our staff is made up of former Fire chiefs, EMS directors, paramedics, EMTs, and other first responders and public safety professionals. We know EMS.

We’ve also always been a technology company. Ambulance Commander will remain the same efficient processing platform that has powered our EMS billing services for years. We’ve always invested heavily in this area, directing our time and resources to improving our proprietary platform’s speed, availability, and transparency. Our in-house teams have spent countless hours on research and development. Digitech’s developers not only continuously incorporate client feedback and fine-tune processes with client goals and needs in mind, but also react instantly to the unexpected, like legislative mandates, reimbursement changes, and public health emergencies. Now, we will be able to dedicate even more of our efforts to Ambulance Commander. We’ll be rolling out more user-friendly features, careful automations, and informative reports.

As we launch into the first merger or acquisition in Digitech’s history, we more than double our staff and customer base. We have a tremendous opportunity ahead of us to expand our reach in the EMS community, to innovate more, to continue our tireless dedication to our mission. Among the many compelling strategic reasons for this transition, we pledge to maintain the same goal we’ve had since 1984: make every client feel like they’re our only client.

Innovative Technology in the Face of Crisis

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As the first line of defense in our communities, EMS personnel need support now more than ever. Agencies and organizations across the country are pooling their resources to help serve and make a positive impact during this crisis. 

Sullivan County Emergency Medical Services, the primary EMS provider for Sullivan County, TN, provides aid to about 150,000 citizens and visitors, as well as those in surrounding communities. A number of ambulances and first responder agencies spread across Sullivan County are ready to respond at a moment’s notice, as their mission is to provide “the best emergency and non-emergency care to patients and their families at the worst times in their lives.” 

The progressive care provided by the service personnel of Sullivan County EMS (SCEMS) is often described as an “extension of the emergency room,” where the years of experience offered by the County’s personnel of highly-trained Medical Directors, Paramedics, and EMTs allow them to maintain a “continuity of care from the place of origin to the hospital.” Since 1970, it has been their prerogative to have as many trained personnel on scene of an emergency as soon as possible. 

In this particular line of work, “seconds count,” and Sullivan County EMS has committed to having the right systems in place in order to lower response times to medical emergencies within their growing communities. Part of their ability to provide such timely service is due to Sullivan County’s tiered response system, which allows for readily-available, localized teams to respond preemptively:

“These response teams bring manpower and multiple levels of training –from Medical Doctors to First Responders– to the crisis environments faced by our  Paramedics and EMTs quickly and efficiently. These teams are highly lauded amongst emergency medical personnel for their selfless acts.  With their short response times, they have repeatedly induced appropriate care and –most importantly– prolonged viability of life in the field prior to our arrival.” – Gary Mayes, Regional Director

Sullivan County EMS is not alone in providing care and support for their people. In this rural community, EMS is a third service for the County, acting as an extension of the Sullivan County Regional Health Department (SCRHD). The SCRHD also helps to prepare the County for public health emergencies. Their Public Health Emergency Preparedness Department, recognized by NACCHO Project Public Health Ready, uses “an all-hazards approach for emergency planning, focusing on situations that specifically affect the health of the public.” The SCRHD serves the communities of Kingsport, Bristol, Bluff City, and Piney Flats within Sullivan County. Their department’s workforce of around 90 personnel also works closely with the Northeast Tennessee Healthcare Preparedness Coalition in preparing their response to public health emergencies like the one we are experiencing today.

The collaboration between Sullivan County EMS and their Health Department combined with their support from Digitech as an EMS billing partner has inspired inventive measures to combat the COVID crisis. As technological innovation is at Digitech’s core, the evolution and design of new tools in the Ambulance Commander software system ensures that partners will have access to such timely solutions. With data gleaned from Digitech’s recent COVID-19 Symptom Map, Sullivan County has been able to identify the areas within their community in the greatest demand of care. This insight allows them to strategically place future COVID-19 testing sites, so Sullivan can continue to support their most vulnerable populations. 

“The COVID Symptom map can be a helpful tool in mitigating the virus by determining specific communities that may need testing, quarantine, or treatment. It allows EMS and Health departments to work collaboratively during the COVID Pandemic.” – Brandon Alley, Sullivan County EMS

The gears continue to turn in Sullivan County as leaders look to this new Ambulance Commander tool for even more creative solutions in the future, like tracking flu-related incidents. 

Between these partnerships and updating their Facebook page with information and guidelines on COVID-19, mental health tips, and to thank individuals making donations to support their emergency service providers, Sullivan County EMS continues to commit to their mission of looking out for every single one of their neighbors in need. 

 

Sources:

New Utilities in Ambulance Commander

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Coronavirus Incident Tracking Tools

Our ability to adapt to an ever-changing EMS landscape is a benefit to our clients. We’ve released new tools to help track Coronavirus-related incidents in your service area. 

With this latest development, Incident Mapping allows you to:

• Isolate incidents by diagnosis code
• Get a color-coded visual map of your service area’s hotspots
• Interactive maps allow you to drill down to the individual call record
• Adjustable settings to scale heat map coloring based on call volume and service area geography
• Built in integration with Triage utility to display COVID-related pickup locations regardless of provider’s impression

Reach out to your account manager for detailed training by clicking here.

Important COVID News

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From all of us at Digitech,

For the duration of this Public Health Emergency, we remain committed to assisting the EMS community by sharing important, up-to-date information with all of our friends and partners. Keeping our clients informed on the most recent updates related to COVID-19 continues to be a top priority. Below is a list of important COVID-19 related industry changes:

  1. CARES Act Provider Relief Fund – legislation has passed that provides $100 billion in relief funds to healthcare providers on the front lines of the coronavirus response. Due to the importance of delivering the funds expeditiously, the Department of Health and Human Services (HHS) is distributing $30 billion of the relief funds immediately. Please find a summary of the program below. Click here for more details.
    1. The payments are not loans and will not need to be repaid.
    2. Payments will automatically be received if your organization received Medicare (FFS) reimbursement in 2019.
    3. The payments will be received via ACH with a payment description of “HHSPAYMENT”
    4. Within 30 days of receipt of payment, providers must either accept the payment by signing an attestation and accepting the Terms & Conditions or contact HHS and remit the payment as instructed
    5. HHS has provided a formula for an estimate of the amount expected which is the amount paid by Medicare in 2019 divided by $484 billion and multiplied by $30 billion. Please contact Digitech if you would like assistance with calculating your estimate.
    6. The CARES Provider Relief Fund Payment Attestation Portal is now available through hhs.gov/providerrelief.
  2. Medicare FFS Sequestration Suspension – The CARES Act has temporarily suspended the 2% payment adjustment currently applied to all Medicare FFS claims due to sequestration. The suspension is effective for claims with dates of service from May 1 through December 31, 2020. Providers can expect to receive an increase of 2% more in their Medicare payments during this time period as compared to prior to the suspension.
  3. Beneficiary Signature Rule Change – Crew members can now obtain a “verbal consent” from the patient to sign on behalf of a suspected or known COVID patient. It is important to note that an actual patient signature is still required in the event the patient is physically or mentally capable of signing and is not a suspected or known COVID patient. Click here for more details, and here for an updated signature form.
  4. Alternate Destination – CMS has temporarily expanded the list of allowable destinations for ambulance transports to include any destination that is able to provide treatment to the patient in a manner consistent with state and local EMS protocols.
  5. Accelerated Payment Process – In order to increase cash flow to providers of services impacted by COVID-19, CMS has expanded the current Accelerated and Advance Payment Program to a broader group of Medicare Part A providers and Part B suppliers. The expansion of this program is only for the duration of the public health emergency.  It is important to note that these payments are subject to recoupment. Click here for more details.
  6. CMS Relaxes Physician Certification Statement Signature Requirements – The Centers for Medicare & Medicaid Services (CMS) has released guidance that recognizes the difficulty ambulance service providers and suppliers may have during the COVID-19 Public Health Emergency (PHE) in obtaining a physician certification statement (PCS) signed by a physician or other authorized professional. CMS and its contractors by extension will not deny claims during a future medical audit even if there is no signature for non-emergency ambulance transports, absent an indication of fraud or abuse. Ambulance service providers and suppliers should indicate in the documentation that a signature was not able to be obtained because of COVID-19. The AAA advises completing the PCS form and then indicating if a physician or other appropriate person has not signed it by writing “COVID-19 Public Health Emergency” on the signature line. CMS also reminds providers and suppliers that medical necessity still needs to be met. The full Q&A document can be accessed here.
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If you have any questions at this time, please reach out to us.

Where in the World is Digitech – Q1 2020

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Tradeshows and Events

Digitech’s road warriors are starting 2020 with a busy schedule full of industry conferences. These events are great opportunities for us to stay at the forefront of the latest trends in EMS and revenue cycle management, and we always look forward to meeting our clients and new contacts on the exhibit hall floor or over a meal after hours. Here’s where you can catch up with us for the first few months of 2020.

Fire-Rescue East

Where: Hilton Daytona Beach Convention Center, Daytona Beach, FL

When: January 22-25, 2020

How to Find Digitech: Exhibit hours are on Thursday, January 23 from noon to 6 PM; Friday, January 24 from 10 AM to 4 PM; and Saturday, January 25 from 9:30 AM to noon. Find us at Booth #1027 in the Exhibit Hall.

Fire-Rescue East - Digitech Booth

 

TASA Mid-Winter

Where: Park Vista Resort, Gatlinburg, TN

When: February 19-21, 2020

How to Find Digitech: Our team will be exhibiting and mingling in the Park Vista Resort for the duration of the conference. You can find us in the vendors’ exhibit area, or catch us at breakfast or lunch.

TASA Mid-Winter - Digitech

 

Virginia Fire Rescue Conference

Where: Virginia Beach Convention Center, Virginia Beach, VA

When: February 19-23, 2020

How to Find Digitech: We will be exhibiting on the show floor at Booth #15 during the exhibit hours of 2-6 PM on February 20, 10 AM – 5:30 PM on February 21, and 9 AM – 1 PM on February 22nd.

 

ESO Wave

Where: Hilton Austin, Austin, TX

When: February 24-27, 2020

How to Find Digitech: We’ll be spending time with our clients and ESO friends during this conference. You’ll see us as both a conference sponsor and an exhibitor at the conference hotel. 

 

EMS Today

Where: Tampa Convention Center, Tampa, FL

When: March 2-6, 2020

How to Find Digitech: Visit us on the exhibit hall floor at Booth 412. We’re also one of the sponsors for the the $10,000 cash giveaway – good luck!

 

GEMSA Directors and Leadership

Where: Legacy Lodge & Conference Center at Lake Lanier, Buford, GA

When: March 23-25, 2020

How to Find Digitech: We’ll be at our exhibit booth in the hotel lobby – see you there.

 

PWW abc360 – Las Vegas

Where: Planet Hollywood Resort, Las Vegas, NV

When: March 22-26, 2020

How to Find Digitech: One of our experts will be speaking at the XI session, and we’ll be at our exhibit booth during the show.

Solving the Deductible Dilemma with Automation

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At Digitech, we don’t see problems—we see opportunities. When a client brings us a question or a problem, we turn it into a challenge. How can we develop a solution that will become a benefit to all who we serve? Can we increase efficiency? Can we write new software that eliminates a roadblock? Can we chart a path through the maze that will lead others out of the same trap?

Take the problem of increasing deductibles in healthcare insurance programs. With costs for health insurance pushing a greater portion of the burden onto the patient, it’s naturally gotten harder to collect ambulance billing claims. Some billing companies might shrug and say, “Well, we’re just going to have to live with a reduction in insurance collections and an increase in self pay claims.”

Not here.

At Digitech, we got to work. We’ve rolled out new automation that enables our verification process to check the deductible information on commercial insurance coverage on a case-by-case basis. For those payers that provide this information, it will be captured in the claim record and will allow us to see whether that claim will hit the patient’s deductible. When a significant portion of the bill may get pushed to the patient, we can hold the claim for a period of time to allow for a greater chance for the deductible to be met. This process is in addition to our standard process of holding Medicare and some Medicare HMO claims for deductibles.

The goal here is the one that Digitech always pursues, while keeping a sharp focus on compliance: Maximized revenue for clients and minimum distress for patients.

Going forward, all Digitech clients can opt in to this program. We’re ready for you! Please reach out to your account manager at Digitech to opt in to deductible eligibility checks and we will get the ball rolling for your service.

You may also contact the Digitech team at accountmanagers@digitechcomputer.com.

Ambulance Cost Data Collection Update

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The ambulance industry has been abuzz about cost data collection requirements set forth by the Bipartisan Budget Act of 2018. As the system continues to develop, we will provide updates about the timeline, any modifications to the requirements that may arise, and how you can take action. Read on, or download this information as a PDF.

What is the purpose of H.R. 3729, the “Comprehensive Operations, Sustainability and Transport Act of 2017?”

  • Medicare Ambulance Add-On Payments, an important supplemental reimbursement source from Medicare, expired on January 1, 2018.
  • Congressional action was needed to restore the add-on payments and they were extended with some reductions by the Bipartisan Budget Act of 2018 until December 31, 2022).
  • There is a current lack of cost reporting data among suppliers of ground ambulance services.
  • This legislation would help CMS understand how much it costs to provide ground ambulance services to Medicare beneficiaries.
  • This act would reauthorize the add-on payments for five years as well as create a cost-reporting system that will lead to improvements in the Medicare Ambulance Fee Schedule and adequate payment rates for Medicare transports.
  • H.R. 3729 will authorize CMS to design and launch a cost reporting system.

What does the implementation look like?

  • Pre-Rulemaking — CMS will engage stakeholders to solicit recommendations.
  • Rulemaking — CMS will publish a proposal for collecting cost data then seek public comment.
  • Final Rule — CMS will issue a final rule after reviewing public input.
  • Launch — CMS will select ambulance services to submit data.
  • Phase One — All ambulance service suppliers will provide data on the characteristics of their operation such as the type of supplier (e.g. volunteer rescue squad, private company, third service, etc.).
  • Phase Two — A survey will collect cost data from a statistically significant number of each group of supplier and provider to obtain costs and other data.

What will this mean for ambulance service providers who are selected to provide data?

  • This is not like Medicaid cost reporting, state reporting, or GEMT reporting.
  • Costs for providing services vary greatly due to differing state, local, and agency protocols like bundling.
  • Different providers have different fee structures and CMS needs the whole range.
  • A representative sampling of providers will be selected to report cost, revenue, utilization, and other information as determined by CMS.
  • Data will be collected each year from 2020 through 2024.
  • Cost reporting will continue at least every three years from 2025 on.
  • Future reimbursement will be dependent on the accuracy and completeness of the data compiled.

How can you take action?

How can Digitech help you?

If you are selected, Digitech will support you through the cost data collection process by providing relevant revenue data and other resources and tools. Our reporting and data mining systems will ease the delivery of required revenue data for our clients. If you have questions about what this all means and how it may affect you or your service, do not hesitate to reach out to us.

Same Dashboard. Better Results.

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You asked, we delivered. 

All New Features on Digitech’s highly acclaimed  

Digitech’s development team has added some cool new features:

  • Multi-select Filtering – Drill down on multiple data points at once
  • Zooming and Scrolling – Zoom in your horizontal view to better view large numbers of data points
  • Legend Quick-Filter – Hide or show data points with a checkbox in the legend
  • Cross-hair – Show a vertical cross-hair to make reading line graphs easier

Let us know what you think! Reach out to our Account Managers if you have any questions.

Using Data Analytics to Build Business Acumen

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Budgets, reports, revenue cycle management, cash flow, forecasts – there is a mountain of financial data that the modern EMS provider has to track to be an effective organization. What should the Operations Chief or Chief Financial Officer expect from their billing company? Here, we explore the analytical solutions developed by Grady EMS that have helped the 911 service provider for the City of Atlanta to stay ahead of the game.

Presenters:

  • Tamara Nilmeier, Director of EMS and Physician Revenue Cycle for Grady Health System, Atlanta, GA
  • Michael Colman, VP – EMS Mobile Advanced Practice at Grady Health System
  • Mitchel Holder, Executive Director of Analytics at Digitech, former Battalion Chief of Business Services for Gwinnett County Fire and Emergency Services

In-House Billing Is Out of Control

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It’s been argued that in-house billing affords ambulance companies more control. You can, after all, walk into your billing manager’s office and ask questions. But don’t confuse proximity with getting the answers and information you need to increase billing productivity. We’re long past the time where geography is meaningful when it comes to data. That’s why companies got rid of their servers — server farms do the job better.

So it is in billing services. Location is irrelevant; concentrated billing expertise and infrastructure are essential. One call to a billing service gets you more help than someone down the hall — even someone with a lot of experience. Reason? An internal billing manager processes 25,000 or 50,000 transports a year while a billing company expert processes a million transports a year for 100 different entities while surrounded by experts in government compliance, insurance industry regulations, and Information Technology. Where are you more likely to get the best information?

You could say control is your access to information that is critical to your decision-making, in which case you have less control than you think. You have some flexibility, assuming you have someone in-house who has some skill with running reports, or you pay the software vendor to produce the reports. Compare that with a billing service with proprietary software and a comprehensive and customizable reporting system. The billing service has an analytics team of IT pros and industry specialists who can produce any report you can imagine for little or no cost. They’ve also gone up the learning curve, so you don’t have to. In fact, they may have already solved your problem because they’ve worked on it with other clients.

Or perhaps your definition of control is the ability for management to make changes to the billing process or personnel as needed. That’s a bit more difficult to tackle. When does the owner of an ambulance company realize she needs to make a process or personnel adjustment? Probably when cash flow is crippled or an audit reveals errors that entail a sizable pay back – in other words, when it’s too late. And when the decision has been made that change is required, how does that get done? Do you now dig into the billing process, hope you can understand it better than the current manager, and then implement the change yourself? Or do you replace the billing manager? If so, where does that new manager come from? It’s not as if experts in ambulance billing with strong management skills are on every street corner. And what of the people in that department that might be loyal to the old manager?

While we’re on the subject of change, let’s assume you can sense the financial benefit of a software change. You know in your bones that you can save $40,000 a year in payroll if Utility X can be developed or modified. Who do you think is more likely to deliver that development? Hint: probably not your software vendor. They avoid software modifications like the plague because every change made for you has to be transferred to 100 other clients. The vendor also knows that every now and then a client will be lost because they hate a change so much. Billing services are built for change because continuous improvement is a basic component of their proprietary software. They understand they will likely benefit from change because it will also make their job easier.

Maybe control is the ability to have an external auditor conduct an audit at will. Engaging an industry expert to audit a claim sample is pretty easy if you have the budget. Realistically, ambulance company owners rarely do, because it’s distracting, it’s time consuming, and it may test morale. Billing services, on the other hand, do these things as a matter of course and will often send you summaries of the reports. They thoroughly understand the process in that they probably go through more audits in a year than most ambulance companies go through in a lifetime. They have a verifiable track record. And you have control in knowing you can push the audit button at any time, even if you rarely do. 

Ultimately, control is about the ability to make changes seamlessly whenever circumstances dictate change is necessary. The ultimate control is being able to replace a billing service without causing too much disruption. You simply start talking to other billing services, give them some data, and ask them to show you how they can solve whatever problems you have and provide better solutions. The conversion process may be a bit stressful, but it is manageable — assuming the service has a decent transition process. That part you can verify from references.

It may seem odd to suggest that billing services are interchangeable parts. They’re not. Some are better than others. But being able to replace them quickly gives the ambulance company operator the ultimate control: You’re never stuck with an underperformer.

The Dirty Secret Your Software Vendor Won’t Tell You

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Companies that sell billing software to the ambulance industry never fail to promise that their software will increase efficiency and profits. What they haven’t mentioned is that their software improves their efficiency and profits, not yours. To achieve that, they sell software that is inferior by design. There. We said it.

To be fair, they have no choice. Software companies can’t make money selling billing software to the ambulance industry – at least not real money as defined by the technology industry. So they have to sell low performance products to maintain their bottom line. How can this be, you ask?

Let’s say a software company somehow captures the entire New York City non-emergency medical transportation market, one of the largest non-emergency medical transportation markets, at approximately one million transports per year. Say that software company wins a killer deal by charging ambulance companies $2 per transport to use their software (about four times the current market rate). Ultimately, after snagging an impossible share of the market and charging an outrageous rate, the software company generates $2,000,000 in annual revenue – less than the annual revenue generated by the average McDonald’s franchise. Consider that for a second: a software company dedicated to the ambulance industry can’t survive by dominating the largest market on the planet and overcharging.

Given this limited revenue potential, the software companies can only afford to build mediocre, fairly generic products, and they can’t afford to market them as anything less than cutting edge. These vendors will point to their software’s well-organized process flow – but that’s exactly the flaw in the argument. In this system, claims are moved from bucket to bucket within measurable time frames. The system just has to keep track of the claim, and all the biller has to do is manually move the claim from one bucket to the next. How’s that for automation? It’s not particularly efficient, but the software provider benefits because the client needs more seat licenses to keep the volume of claims moving. The software system stays simple and cheaper to maintain, which improves the software company’s profits.

A software manufacturer will similarly avoid adding features that maximize collections because those features require additional system complexity, which increases development costs and complicates implementation, training, and maintenance. In other words, it’s a loss for them to help you collect more.

Here’s the good news: Given that the billing software sold to this industry is weak, at best, there is a significant opportunity to improve collections and efficiency with the right technology and the right partner. You need a vendor whose goals are in line with yours.

The only entity incentivized to develop the technology that will maximize efficiency and collections is a billing service that lives for the challenge of continuously evolving new solutions – because really, they’re the only ones who can afford to. They know that the more automated the process, the more code is required, which increases development and maintenance costs. But they also know that extra development expenses result in improved labor efficiencies, allowing fewer people to handle more claims, collect more dollars per claim, and collect on a higher percentage of claims.

Effective billing companies improve by analyzing exceptions, not ignoring them. When enough similar exceptions are found, the truly efficient billing company is able to build a new automated process flow to capture and properly handle those claims. This kind of company sees agencies’ problems as opportunities instead of obstacles, which creates a rewarding partnership.

So if you accept the notion that technology is the key to maximizing efficiency and collections, the answer should be clear: You need a complete billing service with proprietary software.

Finding Money Ain’t Cheap

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Should your ambulance billing service collect $16 million in billings for you or $20 million? Seems like a stupid question. But what if the service knows they will make a profit of $240,000 on the $16 million but only $140,000 on the $20 million?

It’s more expensive to process claims that involve denials, appeals, and multiple phone calls. If your billing service collects an average of $250 per transport and charges 5% of collections, they make $12.50 per claim. What are they supposed to do with claims that need a $20-an-hour-employee to stay on the phone for an hour? Some billing services will ignore these claims; it’s more profitable to write them off and send them to the collections graveyard. And if you’re the EMS client, it’s your agency that loses, not the billing service.

Perhaps you are thinking your billing service has an ethical obligation to work every claim, and if you agreed to pay a set fee per claim, they clearly do. But when the fee structure is an incentive-based percent of collections, things get a bit murky. When paying a percent of collections, you’re basically telling your billing service, “We want you incentivized such that the more money we make, the more money you make – and if we make no money, neither do you.” If that’s the case, is it really a violation of the deal for the billing service to choose not to make money for you on the claims that are not profitable for them?

Everyone in government and business is looking for the best price. EMS chiefs and finance officers have to consider the lowest-price option when seeking bids for goods and services. That’s not only logical, it’s the law in many cases. But low cost and cost effective are not the same thing. Every good manager knows this. Yet when purchasing decisions face the scrutiny of an elected board of commissioners or a finance director or a purchasing office, managers need to have a strong justification for not buying the cheapest available product. Municipalities need to keep two things in mind: First, the profit-oriented private sector does not think like the politically accountable public sector; second, it’s really difficult to beat people at their own game.

For manufacturers and service providers, lowering the price has a number of ramifications, not all of which are pleasant. On the plus side, a low price:

  • Forces efficiencies
  • Makes a business clarify what’s essential
  • Fosters competition

But there are negatives too, including:

  • Forces cost cuts that affect training, support, and the quality of life you can provide to your employees
  • Quality gets compromised
  • The safety and security of your people, your PHI, and your investments may suffer

Any seller can cut price, but great brands offer something beyond low price – convenience, dependability, service, or innovation, for instance. Consider Jet Blue in the airline industry or Amazon in retailing. In the world of EMS billing, that “something beyond” is the ability to process every claim profitably while charging a competitive fee. Few ambulance billers can do that.

The math of collections is worth doing. You may be able to realize double digit collection increases with a single digit fee increase. The higher fee will cover the costs of the technology and advanced processes that can increase collections far beyond the difference you may be paying out. While initially more expensive, applying advanced technology to pursue every dollar on every claim will produce a substantial amount of incremental revenue.

Fire chiefs, revenue cycle managers, finance directors, and municipal officials need to consider their options carefully when making decisions about which billing company offers the best value for their organization. You might think you’re getting a bargain with a billing service that offers a low cost per claim, but just because something is cheaper doesn’t mean it’s a better value. When you’re paying people to find you money, don’t be surprised if they find more when you pay more.

The Right Partner

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optimizeEvery growing business is faced with critical, make-or-buy decisions. Accounting, tax, customer service, office management, maintenance — at some point these functions suck up too much time and resources to be handled internally. They distract you from your company’s main task: delivering a valued service to customers.

That’s especially true for billing: Outsourcing your billing with the right partner will outperform in-house billing every time. That partner will collect more, cost less, maintain a higher level of compliance, and often provide better reporting and analysis.

Why? Because the right partner’s collection software is better than your collection software — even if you’re buying from a third-party software “specialist.” You’d like to think that buying from a third-party vendor will give you the best-performing software available. But that’s not the case. In fact, using a third party vendor can almost guarantee that you won’t have best-in-class collections. That might seem contradictory. After all, wouldn’t a software specialist strive to provide the best product out there? The answer is no. The specialist’s business model doesn’t work that way.

A company that bills in-house must do two things to maximize profit: 1) collect everything it’s entitled to; 2) be as efficient as possible – that is, minimize the number of billers in the department. To try to accomplish that, the firm purchases billing software from among the small group of vendors that specialize in ambulance billing software.

This is where the economics get interesting, and not necessarily in a good way. The third party software companies are similarly striving to maximize profitability, which turns the vendor-client relationship into a zero-sum game. That means the more you get, the less they get — and vice-versa. Some partnership. To enhance their own profitability, software companies have an incentive to minimize the efficiency of their own product and pay less attention to helping clients maximize collections.

And therein lies the rub that has cost ambulance companies millions over the years. The contemporary software model is to sell by the seat license. The more seats a software vendor sells, the more revenue it earns and the higher its long-term (forever) monthly support fee. That system has worked pretty well for Microsoft, a company never accused of being customer-centric. If a billing software company boosts efficiency, it will sell fewer seats. Even worse, increasing the software’s efficiency also increases its complexity, which in turn raises costs for development, implementation, training, and support. Overall, that’s a really bad deal for the software company — inflating costs to reduce revenue has never been a good long-term business strategy.

Somewhat perversely, the software company is similarly incentivized to resist helping its client improve collections. To improve collections requires developing and testing new modules, upgrading a working system, re-training billers, and adding support costs. As firms rarely like to upgrade their software, even less so if they have to pay for it, the upgrade cycle becomes difficult. And if conscience, competition, and pride force the vendor forward (damn those torpedoes), losing a client for making that effort will likely recalibrate the conscience instantly.

Why would you lose a client for doing good, you might ask? Change creates frustration at the client’s company, wherein the software company has to deal with the ire that comes with upending the daily routine of billers who benefit naught from the improved collections. That sometimes leads to complaints to the owner who, aware of his complete dependence on his billing manager, may utter something like, “If you don’t like our vendor, go find one you do like.” SURPRISE! The billing manager likes the one that doesn’t need or require continuous upgrades.

The solution is to find the “right” billing partner, meaning not just any billing partner. You’ll need to do a bit of digging. Take a look under the hood. Develop a set of requirements. The good news is that choosing is less subjective than you might think as it revolves around the technology in use – or rather, that technology’s origin.

For starters, any billing service that uses someone else’s technology is in the same position as the entity that bills in-house. In fact, this partner could underperform the in-house group because it’s savvy enough to know which claims are profitable to collect and which aren’t and may decide to focus on those that are profitable. It’s classic Low-Hanging Fruit Syndrome. If they use someone else’s software, remove them from your list.

Identifying the right partner begins with the right technology. You’ll recognize it if they own their own processing software and have made a long-term commitment to improving its efficiency and ability to maximize collections. You’ll know this is the case if:

  • They have a staff of full-time programmers who work exclusively on this software. It’s a bonus if those programmers have a ton of experience with the company.
  • They upgrade their software regularly (weekly) and every client receives the benefit of those upgrades.
  • They can point to specific modules they have released in the last year that have improved collections or efficiency or both.
  • They offer full transparency. In other words, the service allows the client to access the billing system 24/7, produce a list of claims on screen that represent every transport done for a specific date range, and enables the client to drill down into each claim and find out everything that was done to collect that claim.

Those capabilities are a healthy start. You’ll know you have a partner who shares your priorities and has committed resources to achieve them. And you’ll know you have a partner that does not fear transparency. They won’t be trying to hide anything.

But there’s more you can do. If your partner has large municipal clients, you’ll know it has the following qualifications as these are required by many municipalities:

  • The firm has a solid IT infrastructure with good Disaster Recovery systems.
  • The firm has been audited by independent external auditing firms that are experts in the field.
  • The firm has audited, publicly available financial statements.
  • The firm has SOC 1 Audit results, which are reports by external auditor who insure this company meets its contractual obligations.
  • HIPAA and PHI breach data is publicly available.

References should be at the heart of any evaluation. While there are many companies that do ambulance billing, there are only a few that do it on a large scale. And in most cases, clients have moved from one of these top-tier companies to the other. Ask potential vendors to speak to clients that they have taken from competitors and then ask the clients about the circumstances under which they left. Who collected more, who responded better, how did their implementations compare, whose reporting was better? If one company’s name keeps popping up, and that company meets the criteria above, then maybe you’ve found the right partner.

 

 

Apples and Oranges: The Problem with Comparing Collection Percentages

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In completing over 500 responses to RFPs over the past 10 years, Digitech has encountered the requirement of a collection percentage guarantee multiple times. The municipality’s goal in including this requirement, we suspect, is to identify the agency with the higher collection percentage because that agency will collect more money. While intuitively this may seem inevitable, in reality and where medical billing is concerned, it is not.

Experience has shown us that collection rates for ambulance transports are dependent on several factors: the payer mix and demographics of the area, the speed of claims processing, the agency’s rates, treat-no-transport billing or not, and a number of other inputs that are variable across different types of agencies and different geographic locations. What applies to one emergency transport provider may not apply to the next. Even with reasonably accurate carrier mix data, using collection percentages as a means of comparing billing companies can be misleading. Comparing one service’s collection rate to another’s is often a futile attempt to make the apple taste like the orange.

Given the relationship between actual collections and collection percentages, a collection percentage guarantee is often not advantageous to the provider agency. Think about it: Would you prefer a vendor that collects 100% of a $400 charge or 50% of a $1000 charge? Increasing collections often means suggesting that you bill higher ambulance fees that will generate more revenue and, in the process, lower collection percentages.

On average, Digitech collects approximately 99% of the Medicare and Medicaid allowed amounts, between 80% and 93% of insurance, and anywhere from 1% to 8% of private pay. The overall collection percentage depends on the client’s payer mix. For instance, if all claims were Medicare claims, Digitech’s overall collection percentage would be 99%. If the payer mix is comprised completely of private pay claims, our collection percentage would be 8% or below. These are obviously extreme examples, but they illustrate the impact of carrier mix on overall collection percentage.

So if collection percentage analysis is not the best way to compare vendors, what is the alternative? We recommend looking at collections per transport (CPT) because it is generally a clearer measure of collections as it removes variance due to volume. This makes it easier to compare vendors’ performance. Ask the billing companies you’re considering for examples of where they have taken over from other companies and compare CPT. Then call those entities and ask specific questions.

Another way is to look at the technology that each prospective billing company is using and dig into its capabilities. Superior technology is the most significant determinant of success in ambulance billing. The best companies will have mature, well-conceived, customizable software that is specifically designed for ambulance billing.

Finally, references should be at the heart of any evaluation. In many cases, clients have gone from one billing company to another. Ask the clients about the circumstances under which they left their previous vendor. Who collected more? Who responded better? How did their implementations compare? Whose reporting was better? Answers to these questions paint a much more complete picture of prospective companies than collection percentages will.

Collection Improvement Examples

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Digitech has increased revenue recovery for our clients every time we have been contracted. Click on “Before” and “Digitech Year 1” to see how much.