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

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.