Expert EMS Billing

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.

ABCs of EMS Medicaid Funding: The New Rules After OBBBA

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A clear-eyed look at CPE, IGT, and provider tax programs—and how to protect your agency’s budget now.

There’s no siren when a funding stream disappears. No alarm sounds when CMS quietly redefines which costs are reimbursable under Medicaid. But if you’re relying on Medicaid supplemental payments, whether through CPE, IGT, or provider tax, you need to know what recent legislation means for your agency’s budget and future.

A Small Slice of the Medicaid Pie, But a Big Impact

On July 4, 2025, the One Big Beautiful Bill Act (OBBBA) was signed into law, introducing sweeping changes to tax, energy, and entitlement policy. One major provision is a $1 trillion cut to Medicaid over the next decade, driven by new eligibility restrictions, work requirements for enrollees, and limits on Medicaid financing plans, also known as supplemental payment programs. These cuts raise concern for EMS providers in more than 30 states who rely on supplemental payments for critical revenue. While some impacts are obvious, others will vary depending on the type of program in use within each state.

At Digitech, we’ve seen the confusion firsthand. EMS leaders across the country are trying to make sense of the patchwork of Medicaid supplemental payment programs in play. And we get it. The alphabet soup is dense, and the funding rules vary by state. But understanding how these programs work is important, especially now. EMS receives just a fraction of what hospitals take in through supplemental payments — less than $500 million annually, by our estimates (as no aggregated numbers exist for EMS), compared to $94 billion for hospitals in FY 2022.[1] The impact on EMS is outsized in relation to this small piece of the federal spending puzzle. For many overworked, chronically underfunded systems, these dollars aren’t extra. They’re critically important to the viability of EMS.

How State Dollars Unlock Federal EMS Funding

Despite their different names and acronyms, all EMS supplemental payment programs work in a similar way: they use state funds to pull down federal matching dollars. Because Medicaid is a joint state-federal program, for every dollar a state “spends,” the federal government provides a matching percentage—anywhere from 50% to 77%, depending on the state’s per capita income. (States with lower income levels get a higher federal match.[2]) This core funding structure is what makes supplemental payments possible and why changes to the rules at either level can directly impact EMS budgets.

The Common Thread in All EMS Supplemental Programs

ABCs of EMS Medicaid Funding Graphics

Similarly, Medicaid programs are jointly administered by the federal and state governments. Any changes provider payments or covered services at the state level needs federal approval. The OBBBA brings some of the most significant shifts we’ve seen in Medicaid financing in decades, and that includes the supplemental payment programs many EMS providers have depended on for a decade or more. If your agency relies on these dollars to keep units staffed and ready, expect changes ahead.

Three Paths to Supplemental Medicaid Payment

Before we dive into the possible impact of restrictions or changes that the OBBBA may bring to Medicaid supplemental payments, it’s important to understand the three main types of these programs commonly used by EMS agencies:

  • Certified Public Expenditure (CPE): Used by government agencies, this model allows providers to report the actual cost of delivering Medicaid-covered ambulance transports. As allowed through a State Plan Amendment approved by CMS, an eligible EMS entity may voluntarily certify public funds spent to support the cost of providing a Medicaid-covered service (e.g., ambulance transport). CPE programs can go by many names, including Ambulance Services Supplemental Payment Program (ASSPP), Emergency Service Transporter Supplemental Payment Program (ESPP), Ground Emergency Medical Transport (GEMT), Public Emergency Medical Transport (PEMT), amongst others.

  • Intergovernmental Transfer (IGT): In an IGT program, a local government entity (like a city or county EMS agency) transfers funds to the state Medicaid agency before a Medicaid payment is made. The state agency then uses this money to draw down federal match. The combined funds are returned to providers as supplemental payments. Each state makes its own decisions, within federal requirements, regarding how to finance its share of the Medicaid program. Generally speaking, these are often linked to State Directed Payments (SDPs) and used to support Medicaid Managed Care transports. The enhanced payments may be established at statewide average cost, Average Commercial Rate (ACR), or Medicare.

  • Provider Assessment (Tax): Unlike CPE or IGT, this is a broad term for a program that funds State contributions toward Medicaid healthcare expenditures in order to secure matching federal funds. Provider taxes may benefit both governmental and private EMS agencies, depending on regulation and CMS approval. To qualify, the taxes must be broad-based and uniform – levied at the same rate across all providers in a class, and providers cannot be held harmless (direct/indirect guarantee that each provider will be repaid for the amount of taxes paid). There’s a federal “safe harbor” if the tax stays below 6% of net patient revenue; the indirect guarantee does not apply if the tax rate falls at or below the safe harbor limit.

Medicaid Supplemental Payment Programs at a Glance

Type of Program Certified Public Expenditure (CPE) Intergovernmental Transfer (IGT) Provider Assessment (Tax)
Entities Eligible Governmental Governmental Governmental, nonprofit, and for-profit (private)
Reporting Requirements Annual cost report Cost report or average commercial rate survey Net patient revenue report
Medicaid Payment Delivery Systems Covered Typically, Medicaid FFS (in Texas, CPE is utilized for uninsured charity care reimbursement only) Typically, Medicaid MCO but may also be utilized for Medicaid FFS Medicaid FFS and Medicaid MCO
Approvals Needed State Plan Amendment (SPA) CMS preprint Typically, state legislation and CMS preprint
Frequency of Approvals Once approved, remains in effect until amended Must be re-approved annually/biennially Must be re-aproved annually/biennially
Audit/Desk Review Requirements Yes No No

Now that we’ve defined the three programs, we move on to how these programs work.

CPE: How It Works and Where It Falls Short

In CPE programs, participating agencies submit detailed annual cost reports to document the true cost of providing ambulance transports to Medicaid patients.

How it works: If your agency calculates an average transport cost of $2000 and the Medicaid allowable (interim payment already received) is $200, the $1800 difference becomes eligible for reimbursement. Assuming a 50/50 state-federal match, you’d be eligible to receive $900 in federal funds. But there are three key limitations:

  1. A CPE is only available for governmental providers.
  2. Only Medicaid Fee-for-Service transports are eligible for reimbursement under a CPE. If your state has transitioned most enrollees to Medicaid Managed Care through a managed care organization (MCO), the funding opportunity through a CPE can be very limited.
  3. Cost reporting introduces administrative overhead on the state and participating providers to maintain CMS compliance. This can be a significant burden.

Not sure how much of your Medicaid population is covered by FFS vs. MCO? Check with your billing vendor. You can also get a rough estimate at kff.org.[3] They estimate that the national average is around 75%.[4]

IGT: Filling in the Gaps in Managed Care States

While traditional CPE programs work well in states that have a majority of their claims covered by FFS, an IGT-based supplemental payment program may be layered on to cover costs related to Medicaid MCO transports.

In this scenario, a governmental EMS provider sends funds to the state Medicaid agency, which then uses those dollars to draw down federal matching funds. The combined funds (local and federal) are distributed back to the participating providers as supplemental payments. States may use IGT programs based on average statewide costs (which requires cost reporting) or Average Commercial Rates (ACR). But these programs require formalization and an annual CMS approval to remain in place, making them more vulnerable to policy shifts.

Provider Tax Programs: Broader Access, Different Rules

Unlike CPE and IGT, provider assessment (tax) programs are available to ALL EMS agencies, including governmental, nonprofit and private for-profit. Under this model, EMS agencies are taxed based on a formula tied to transport number or percentage of revenue. The state uses those funds to draw down federal matching funds, which are then redistributed to providers in the form of enhanced payments. Providers receive supplemental payments proportional to their Medicaid transport volume, making this a potentially meaningful funding stream for high-volume providers.

Policy Impact: What Does the OBBBA Mean for EMS Supplemental Payments?

CPE Under the Microscope

The OBBBA doesn’t appear to directly target CPE programs, but they are under CMS scrutiny in terms of its interpretation of what counts as reimbursable costs for Medicaid patient transports. Historically, agencies could include readiness costs (staffing, ambulance maintenance, administrative support) in addition to the actual response cost and clearing the hospital. CMS is challenging that readiness piece. In some states like Texas, CMS audits have already excluded readiness costs, restricting the allowable cost to the time when the ambulance crew first comes in contact with a patient to when the patient is dropped at the hospital. This shift ignores the 24/7 readiness that is essential to serving Medicaid patients, even if the clock doesn’t start until patient contact. Without those substantial expenditures, the Medicaid patient could not call 911, receive immediate treatment, and be transported to the hospital. If readiness is excluded, local taxpayers will likely be left to fill the funding gap.

IGT: High Risk, Fast Changes

IGT programs are vulnerable to quick federal changes. CMS could decide to cap allowable costs (reimbursement) at the Medicare rate, which would lower supplemental payments, in many cases substantially. Because IGT programs require annual CMS approval, changes can happen fast with little time for agencies to adjust.

Provider Tax: Uncertain but Tightening

Nearly every state uses provider assessments for at least one provider class (49 out of 50, with only Alaska as the exception), whether that’s hospitals, EMS, nursing facilities, or others. This is why any cuts to provider assessments are an important issue. The ripple effects go far beyond EMS, impacting multiple parts of the healthcare system.

The OBBBA’s impact on provider tax programs is less clear and may vary by state, but CMS has already signaled that changes are coming. Most likely, we’ll see freezes on assessment increases, limits on new programs, and tighter rules for existing ones.

From our work with EMS agencies across the country, we believe provider assessments are the most likely target for significant federal scrutiny. Not only has the OBBBA highlighted them, but CMS has also proposed new rules aimed at closing loopholes in how these programs operate (link to rule).

States that rely heavily on provider assessments to supplement Medicaid funding—particularly those with large Medicaid populations such as Kentucky, Missouri, and Tennessee—should prepare for possible revenue contraction. One lesson from recent experience is that regulatory changes often cause the most harm because of the uncertainty and lag time. You don’t feel the impact right away; it can take months before reduced payments are reflected in your reports and budget. At that point, replacing the lost revenue becomes extremely difficult.

In Texas, for example, Digitech and our clients have had to navigate significant changes to the Ambulance Services Supplemental Payment Program (ASSPP) after cost reports were submitted. New cost allocation and data reporting requirements, likely tied to a federal OIG audit, were implemented midstream, creating delays, confusion, and making it impossible for providers to budget accurately.

We recommend running worst-case scenario models now and factoring in the possibility of delayed or reduced payments. For high-volume Medicaid providers in states that depend on provider assessments, this is a “double whammy” risk. As Medicaid enrollment drops due to new eligibility restrictions, you may face both increased uncompensated care and reduced supplemental funding.

Act Now to Protect Your EMS Funding Future

Given federal spending changing substantially and Medicaid rules tightening, EMS agencies need a clear understanding of which supplemental payment programs they use and how each could be impacted as changes take effect. The exact impacts are still uncertain, as broad legislation like the OBBBA must be interpreted, implemented, and potentially altered over time.

Now is the time to review your funding streams, run scenarios, and start conversations with state partners and local decision-makers. These changes may roll out gradually, but agencies that understand their exposure and plan ahead will be in the strongest position to protect service levels and budgets.

Digitech encourages you to reach out to our Medicaid supplemental payment program experts if you want to discuss this situation in more detail. Talk to us now to understand the potential impact on your agency:

Webinar: Best Practices for EMS Providers Now That Mandatory Cost Reporting is Underway

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Some EMS providers remain unaware that ALL ground ambulance providers are required to provide cost data to CMS, and the first reporting period is already underway. Even if you understand the submission requirements, there are still some best practices to learn that can help the process run more smoothly. In this webinar, Digitech’s cost reporting experts as well as client guest speakers will review the current state of the mandatory cost reporting cycle, share examples and tips from EMS providers’ experiences in the field, and offer insights and resources that will help you avoid the 10% Medicare penalty that CMS will impose if data is not collected and reported accurately.

View the webinar below:

 

Download the slides here.

Check out our recent blog post if you would like to learn more: CMS Cost Reporting in 2023 and the Impact on EMS & Ambulance Medicare Reimbursement: Where Are We Now?

Digitech Learning Center Goes Live

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Pre-hospital patient care documentation training system launches

Chappaqua, NY – April 4, 2019 – Digitech, a leading provider of EMS billing and technology services, announces the opening of the Digitech Learning Center (DLC). The DLC is a new training resource enabling pre-hospital care providers and first responders to deepen their knowledge of a growing array of topics, including a complete, internally-produced documentation compliance course.

The Learning Center’s programs use video-based training followed by quizzes that verify the participants’ knowledge acquisition. Courses are delivered in manageable sections ranging from 90 seconds to 15 minutes. Documenting Excellence, the first training program on the DLC, features eight sections in which all aspects of data collection and documentation of pre-hospital patient care are covered, including operational data, clinical data, history and vital signs, interventions and observations, billing data, and writing complete and compliant narratives.

The DLC’s programs are designed for busy EMTs, firefighters, and paramedics who can do the work at their convenience—on the job, in a coffee shop, at home, or wherever there’s a free moment and good WiFi. Mobile devices and desktop systems all work equally well to consume the training. The coursework is supplemented by an array of resources and references that participants can use to further advance their documentation skills. Onscreen instructors include EMTs and Paramedics from Digitech’s staff, and material for the courses was developed in conjunction with our Certified Ambulance Coders and Quality Assurance experts along with seasoned Emergency Medical Services professionals at Digitech who understand the components and the value of clean, compliant patient care reports.

“We’re excited to offer this new resource to our clients,” said Mark Schiowitz, CEO and President of Digitech. “This medium makes it possible for EMTS to learn on their schedule and for their agencies to benefit from critical training without the huge costs and inconvenience that goes with gathering groups by taking them off the road. It’s quicker, easier, and better than the traditional classroom approach. The testing and scoring system enables EMS managers to track progress and monitor completion of assignments.”

Digitech has provided EMS billing services to clients across the United States since 1994. “We are a technology company, and the Learning Center is a continuation of our tradition of delivering high-quality, high-tech service and support to the EMS and Ambulance community,” adds Walt Pickett, Digitech’s Chief Operating Officer.

To view this press release as a PDF, please click here.