Expert EMS Billing

EMS PCR Signatures Explained: Compliance, Audits, Complete Reports 

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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. 

Preventing Costly EMS Documentation Mistakes: Best Practices  

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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. 

Low Medicare Rates, Higher Stakes: What MedPAC’s Report Means for EMS

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On June 15, the Medicare Payment Advisory Committee (MedPAC) issued their required report to Congress on the Ground Ambulance Data Collection System (GADCS). The GADCS report, Chapter 6, can be found within the full report. 

As expected from the previous draft reports and meetings, the report focused on cost reporting. The recommendations of the report are: 

  • Continue collecting cost and revenue data from ground ambulance providers 
  • Focus data collection on information essential to assessing the accuracy of Medicare payments and Medicare beneficiaries’ access to ambulance services 
  • Pursue opportunities to streamline data collection 

Eight years elapsed from the time that MedPAC was tasked with collecting and assessing cost data until the issuance of this report. The report does share from the data that was collected that costs for ambulance services are largely driven by volume of transports along with ownership type and staffing model type. Costs tend to decrease with size/scale and that rural services operate at higher costs.  

Unfortunately, the original charge to MedPAC to review the adequacy of Medicare ambulance payments was largely not addressed. The report did acknowledge that the Medicare reimbursement amounts established in 2002 were largely set without assessing the cost of providing the services and that using an inflation index to solely adjust rates may not accurately track with the costs of providing ambulance services. It also focused on the fact that there was substantial variability in the data and tied that to concerns that agencies were not consistently reporting costs. Additionally, they stated that government-based EMS agencies were not fully reporting local revenue/tax sources. 

It appears that the next iteration of GADCS should “focus on Information essential to assessing . . . the accuracy of Medicare payments . . .”. As an industry it is important that we continue to advocate that current Medicare payments were never set utilizing the cost of providing the service. It is also critical that the industry continues to educate stakeholders that the emergency ambulance system does not function without paying for the readiness of the system and that cannot be carved out from the actual transport.  

The stakes have also increased now that supplemental Medicaid payments are being anchored to Medicare allowed rates. Artificially low Medicare rates now set a ceiling for reimbursement for the majority of transports agencies provide (Medicare and Medicaid make-up over 2/3 of the services provided for almost every agency). This creates a local burden when the federal and State governments under-reimburse for these essential services. 

Moving Forward

Here are some key takeaways from Digitech’s cost reporting team that we believe could help our industry as we look into the future of Ambulance cost reporting: 

  • The data in the GADCS collection supports the fact that delivery of emergency services is expensive and substantially more than current Medicare allowed amounts 
  • Standardization of EMS cost elements will benefit the industry and allow for more consistent data capture 
  • EMS providers must capture the full set of costs that are involved in the delivery of services to decrease the variability across providers 
  • Data capture and analytics need to be a core capability built into EMS systems, not an afterthought  

Digitech is ready to support industry and individual agency efforts to take cost reporting to the next level. 

Narratives That Stand Up to Audits: 4 Documentation Essentials

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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

 

Federal IDR Operations Rule Update: Key Provisions and Anticipated Impact

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The initial intent of the No Surprises Act (NSA) was to enhance provider-payor relationships in a manner that would increase the dialogue, reduce the number of disputed claims and ultimately result in a higher percentage of in network relationships that would reduce the number of out of network claims across the healthcare system. The Independent Dispute Resolution (IDR) process was envisioned as an exception (rather than the rule) when the initial NSA rules were promulgated. The reality has been quite the opposite. 

The latest installment of the Federal IDR operations rule was released on May 28, 2026. This long, awaited, much anticipated rule makes some adjustments designed to streamline the process and reduce administrative burdens. 

Improving the Exchange of Information 

Both providers and payors have reported difficulty receiving key information necessary to resolve claims on a timely basis. This latest rule makes some adjustments to the process that are intended to reduce the level of confusion in the exchange of information.

  • Standard Reason Codes/QPA Clarification

The new regulations will require payors to use a standard set of claim adjustment reason codes (CARCs) and remittance advice remark codes (RARCs) when they notify providers of their decision. Likewise, payors will be required to provide more consistent information regarding their computation of the Qualified Payment Amount (QPA). This may help providers understand exactly how the payor made its determination with respect to denial and/or payment level. In the case of air medical transports, this may help providers sort out why the payor did or didn’t pay for certain aspects of the services provided. 

  • Payor Entity/Plan Information 

The new regulation requires payors to provide additional identifying information on each remittance. This may reduce the level of confusion later in the process. Since many health plan organizations offer a variety of coverage types/plans. There has been a great deal of confusion regarding plan types that are not currently covered by the NSA. For providers to follow the correct process under the NSA rules, they must know what type of plan they are dealing with. Historically, not having this information has contributed to a great deal of frustration and unnecessary administrative burden for both providers and IDR entities.  

  • Open Negotiation 

The new rule will clarify the 30-business day timeline and require formal submission through the Federal IDR portal. In addition, the receiving party will now be required to acknowledge the activation of the Open Negotiation period. These requirements will formalize the process. The new process should also eliminate  disputes regarding official notice and claim timelines related to the use of the payor portals. The Open Negotiation process, under the current rules, has failed to achieve the intended outcomes: 1) promote a mutual effort to resolve individual claims before engaging the IDR process and 2) encourage provider-payor dialogue in a manner that will reduce the number of future claims that will require resolution under the NSA. The intent of the new regulation is to encourage active participation in the Open Negotiation process. 

  • IDR Registry 

The new rule will require payors to register with the Departments and provide certain additional information regarding the plan eligibility for the NSA-related processes. Following submission, the health plans will be granted an IDR registration number. The intent is for this number to help IDR entities and providers to more easily communicate with health plans and determine NSA related eligibility. This may improve the effectiveness of the process and reduce confusion for both providers and IDR entities.

Streamlining the Process 

The current process has created a great deal of administrative burden for both providers and payors, as well as the IDR entities. The cost of carrying out the process and the resulting delays in payment creates an incredible burden on providers especially.

  • Batching 

The new rule will add some parameters around the batching process under certain circumstances. If a single patient receives related services on the same date, which are submitted on the same claim form (e.g. base and loaded mile charges), the claims should be adjudicated together. This should clarify much of the confusion around breaking air ambulance claims into two separate claims, as opposed to treating them as one (as has been the expectation for decades). This should reduce the number of IDR submissions for air medical services claims overall. 

  • IDR Eligibility 

The new rule will require IDR entities to determine eligibility of a claim for the process within five (5) days of IDR entity selection. In addition, the rule will establish requirements for parties to submit information regarding claim eligibility to IDR entities within a specified timeline. This change is designed to reduce delays in the IDR process and reduce some of the administrative burden experienced by IDR entities and providers. 

  • Extenuating Circumstances 

The new rule makes provisions for exceptions to the NSA timelines for certain specific extenuating circumstances. Since the inception of the NSA, there have been certain situations (e.g. pandemic, portal inaccessibility, natural disasters, etc.) that have made it difficult for the parties to adhere to the required timelines. The intent of the rule is to make the process of granting exceptions clearer. 

  • IDR Fees 

The new rule reduces the IDR Administrative Fee to $15 (from the current $150) and adds some enforcement provisions for both the IDR Administrative Fee and the IDR Entity Fee. The intent is to ensure that all claims that are eligible for the IDR process have access to it and to hold providers and payors accountable for the fees, so the process is sustainable. 

What Does All This Mean for Air Ambulance Providers?

The proposed rules are intended to address several key pain points in the NSA related processes as expressed by various participants. Improving the information exchange and streamlining the NSA related processes are welcome efforts for the air ambulance community. However, there are still several areas where the Departments are working on language that may critically impact how the rule will be implemented. Until we see and understand that additional language, the jury is still out on the effectiveness of this new operations rule. 

Likewise, nothing in this rule addresses several additional areas of concern that have been consistently voiced by the air ambulance community: 

  • Cooling Off Period Confusion 

The application of the Cooling Off Period provisions of the NSA continues to create delays in the IDR process for air ambulance providers. Air ambulance providers typically use two (2) codes (for each claim). The Cooling Off Period effectively shuts down the IDR process for ALL claims with a specific provider and payor for the specified period. This penalizes air ambulance providers unnecessarily. The intent of the cooling off period was to allow for active dialogue between parties regarding in network relationships. Behavior by the payors since the inception of the NSA has proven this concept has failed. 

  • Initial Payment Challenges

With the length of time the NSA related processes take and the lack of guidelines for initial payments, providers are penalized when payors issue initial payments well below what is reasonable. Payors are increasingly paying a small percentage of the claim value (or not paying at all) at the time of initial claim determination. This is forcing providers to wait months or years for compensation for the valuable services they provide. 

  • Payment Enforcement 

Air ambulance providers are still waiting months or years to receive final payment from health plans after a successful IDR adjudication. The original NSA regulations provide a very specific timeline; however, those regulations were silent on enforcement. This provides no incentive for payors to make final remittance on a timely basis. 

These updates are positive steps to alleviate stress in the system. Until the final language for this rule is published AND implemented, the extent of the relief will be unclear.   Additional efforts to resolve the additional key issues noted above must continue. The lack of resolution will continue to put access to air ambulance at risk across the country. The vital role air ambulance providers play is increasingly important with the number of rural hospital closures resulting from the other pressures on the health care delivery system. 

The Digitech team will continue to monitor the processes and advocate for positive change. 

 

Advocacy in EMS: What Does Engagement Look Like?

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In today’s fast-moving world, it can seem daunting to get actively engaged in the political process. Many EMS leaders avoid it completely, whether locally, statewide or nationally. However, allowing policy decisions to happen to us is never a good strategy. The reality of the current EMS environment is that we cannot afford to ignore the opportunity to advocate for our profession and the communities and patients we serve.

Impact on EMS

EMS professionals face a variety of challenges to sustainably provide high-quality, pre-hospital care services. Personnel shortages, drug and supply shortages, funding challenges and a myriad of regulatory expectations make delivering services more complicated than it was 20 years ago. The reality is that government policy is evolving every day, with both direct and indirect impacts on our ability to serve our communities. Changes to Medicare and Medicaid policies, an evolving global geopolitical environment, and many other policy matters are impacting EMS agencies, both in the near term and over the long term.

Key Elements of a Strong Advocacy Effort

Despite these challenges, there are some fundamental elements of an advocacy strategy that can help EMS leaders meaningfully impact the political process.

Get Educated

There are plenty of resources to help EMS leaders understand the policy issues that are impacting our profession. A great place to start is by joining one of the many national and regional professional associations that represent our community. The American Ambulance Association, the National Association of EMTs, the International Association of Fire Chiefs and many others have highly active advocacy programs and tools available to their members. Many of these organizations provide a wealth of information about the legislative and regulatory issues that impact, or have the potential to impact, the EMS world.

Another resource is your vendors and partners; check with them to assess their engagement in advocacy. In our case, both Bound Tree and Digitech have regularly active advocacy teams, working each day to raise awareness and educate lawmakers and regulators about the challenges we face.

Build Relationships

There is a common misperception that those who make policy have their minds made up. The reality is that those who govern are often very open to learning. Take the time to introduce yourself and your organization. Educate those who set policy about the services you provide and the challenges you face. Remember that the people you employ, and the people you serve, are also constituents of your elected officials; a powerful connection that can influence a legislator’s approach to policy decisions.

Build Coalitions

There is value in numbers and consensus. Advocacy isn’t something that succeeds in isolation. Any effort to impact policy is often strengthened by presenting a strong coalition of stakeholders who support an idea or solution. Connect with other organizations, related disciplines and geographically connected groups with which you share common ground. Work together, where possible, to craft and advance your message.

Have an Elevator Pitch Ready

There is always a great deal of noise in the political process, where success is often determined by how simple and memorable the message is. Presenting a 42-point plan to improve the delivery of EMS will not likely get much traction. However, delivering a consistent message regarding the top 3 challenges your organization faces, and 3 “asks” that will help you address these challenges, is something that can build census and momentum. Before you engage with government officials, develop and hone your elevator pitch to tell the story in 10 minutes or less.

Practical Efforts

Whether it’s your town council, state representatives or the U.S. House of Representatives, lawmakers face elections on a regular basis. They are motivated to stay connected to those they represent—and that creates opportunities to interact with them directly.

Hold an Open House

The services you provide, and the way your organization provides them, may not be familiar to lawmakers. Invite them to visit your facility. Scheduling may take some time but get something on the books for when the representative is in town. In some cases, a ride along may be possible. Organize the opportunity around the availability of the official.

Panel Discussions

Ask an elected official to participate in a discussion about EMS. This can be a very valuable experience, as well as a solid relationship-building exercise. Assemble a group of stakeholders, including the representative, to participate on site. This two-way dialogue can both educate the representative about EMS and allow them to help EMS leaders understand the challenges and processes they face.

Photo Opportunities and Remembrances

If you can arrange a visit to your agency, be sure to create a photo opportunity to memorialize the event. A team photo of the representative with your staff, a photo with your equipment in the background, or an action photo with the representative observing a training exercise are examples of compelling images. If you have ever visited a government official’s office, you’ll almost always notice awards and memorabilia the representative has received. The importance of such items cannot be overstated.

Aides are an Important Audience

Most elected officials have staff that assist them in performing their duties and carrying out their service. These individuals tend to be trusted advisors and in many cases are the first step in evaluating whether a specific policy decision is made. Meeting with staff and investing time into building relationships with key staffers is an important part of the process.

Never Too Late to Take the First Step

As you ponder some of these ideas, please don’t allow historical inertia to keep you from moving forward. Start by setting aside some time to get educated, hone your message, seek out and build relationships with key decision makers, and dive in. There is a plethora of policy matters unfolding in the halls of Congress, State Houses, and Governors’ Mansions that will impact how we deliver EMS today and in the future. Don’t let the past limit the future for you and your organization. Now is the time!

For additional insights and ideas, please join us for our Advocacy in EMS Webinar on May 19, 2026. Register here.

What Lies Ahead for Prehospital Care Finances

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From the operational challenges associated with a global pandemic, to staffing difficulties, to ongoing reimbursement shortfalls, it seems as if the Prehospital Care Community in the United States has been under siege for years. And now, as the budget reconciliation process continues in Washington and the Federal Government recalibrates in the post-DOGE era, there are both risks and opportunities for healthcare providers and suppliers.  

Headwinds Ahead

In an ever-shifting landscape, uncertainty has become the norm. Here are some of the challenges that lie before the pre-hospital care community:

Cost Pressures

The cost pressure is no surprise to anyone who follows our industry. However, what does the future hold on this front? It stands to reason that labor costs will continue to rise as certain members of our teams catch up from historically low wages. Shortages of key professionals are expected to continue and, in some cases, accelerate in the years ahead. In addition, the cost of equipment, supplies and technology continues to rise at alarming rates—if you can even get the medications and/or ambulances to put them in.

Government Budget Challenges

As the saga of the Federal budget process plays out in our nation’s capital, we should note there are challenges in State and Local municipal budgets as well. The projected cuts in Federal spending are destined to impact Medicaid, Medicare, and many other healthcare programs. To compound the issue, many State and Local agencies are seeing federal dollars that they relied on for other key programs to cut. Likewise, changes in funding for education are likely to impact the institutions that offer the majority of the training required to develop new EMTs, Paramedics, and Nurses.

Balanced Billing Challenges

The EMS community is entering an era of uncertainty as States continue to address the impact of balance bills to patients. Those of you in the air medical services portion of our community are several years into what we know as the No Surprises Act (NSA). While many states are taking a slightly different approach to addressing this issue on the ground side, the reality remains the same, and our ability to cost shift (make up the shortfall from inadequate government payments, uncompensated and undercompensated care) will be significantly diminished.

Tariffs

While we are still relatively early in the “tariff era,” economists believe the near-term impact will be higher prices for many goods used in healthcare delivery. Some remain hopeful there will be a more positive long-term impact as domestic production of many of these items ramps up. Only time will tell, but it seems logical to assume the current tariff related cost pressures will evolve into significant cost increases for healthcare supplies for the next 1-4 years.

VA Reimbursement Cuts

The stay of execution on VA payment cuts was issued last year. It was a huge relief for agencies that operate in areas with large Veteran populations. However, there is still a need for VA leadership to address the findings of the Government Accountability Office (GAO) study and develop a more balanced payment mechanism for medical transport services to avoid reduced payments from the VA.

Opportunity on the Horizon

At the same time, there are doors that can open even in times of uncertainty. Here are some of the opportunities that may present to the pre-hospital care community:

Market Rationalization

Our organizations operate with very high fixed costs (what we call readiness costs). This means that the ultimate performance metric, cost per transport, is tied tightly to the volume of episodes of care we provide. As economics become more challenging, there are often reductions in the number of suppliers. That reduction creates an opportunity for the remaining organizations to reduce their cost per transport by increasing volumes and getting economies of scale. Of course, expansion of services and/or service areas must be carefully evaluated and implemented.

Medicare Payment Reform

Compiled data from the Ground Ambulance Data Collection System (GADCS) shows that there will now be relatively objective data on the operation of prehospital care organizations. Likewise, the NSA prescribes a similar data collection process for air ambulance service. The air ambulance process should commence with the publication of the final NSA rule. The industry is hopeful this data may be applied to a comprehensive effort to reform the current Medicare payment system. Anyone who has been around the EMS community for more than a few years understands that Medicare reimbursement is less than adequate. For the first time in many years, we may actually have the data to support a rational calibration of the Medicare Ambulance Fee Schedule.

Readiness Movement

In many areas of the country, community leaders have come to grips with the concept of readiness costs. Some communities are making efforts to compensate prehospital care organizations accordingly. While a great deal of work is left to be done in this area, there are certainly models to build upon. This is an area that has the potential to change the economic landscape of EMS in many portions of the country.

VA Payment Reform

While there is still risk the reimbursement payment system will result in dramatic reductions in payment for prehospital care providers, there is also an opportunity for the emergence of a rational system of compensation for the prehospital care of VA patients. EMS leaders need to continue to track this matter and pursue policy change that is balanced and rational.

There is Hope…

As you weigh these many factors that will impact prehospital economics in your own organization and in the years ahead, recognize there is hope and opportunity. There is more movement toward true financial reform than we have encountered in recent years. More data is now available to us. There appear to be emerging champions for EMS payment and financing reform. The industry seems to be more engaged and united in its commitment to achieve rational reforms.

While headwinds are inevitable—and EMS leaders must and prepare their organizations for the storm—we must never lose focus on the opportunities that lay before us.

How EMS Leaders Build Cultures That Drive Performance

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Creating a culture of excellence requires EMS and Fire Service leaders to take an intentional approach to blending optimal clinical outcomes, meaningful continuing education, consistent compliance, and thoughtful organizational management.  

In our recent webinar, More Than Mandatory: How EMS Leaders Are Building Cultures That Drive Performance, we asked a panel of experts to share how they guide their teams to balance everyday challenges with building a culture that can sustain a thriving agency. 

Across three very different organizations—Area Ambulance Service in Iowa, Plum EMS in Pennsylvania, and the Oklahoma City Fire Department—these leaders described culture not as a side initiative, but as a core operational strategy. Their message was consistent: Strong culture doesn’t happen by accident. It is built deliberately, reinforced daily, and led from the top. 

Leadership Sets the Tone 

The conversation opened with a reality familiar to EMS leaders everywhere: The job has never been more complex. Agencies are navigating workforce shortages, financial pressures, evolving clinical demands, shifting regulations, and the cumulative mental strain placed on providers. 

Our panelists agreed that in a constantly shifting landscape, culture is a vital stabilizing force, shaping how EMS teams respond to challenges. Across the board, it was agreed that leadership needs to set the tone to ensure a culture in which employees feel supported rather than burned out.  

“We can talk about culture all day,” said Jennifer Zahrt, CEO of Area Ambulance Service, “but if we’re not out front setting the example, it’s just not going to take root.” 

Oklahoma City Fire Department Chief Richard Kelley emphasized the importance of authenticity in leadership, as culture shows in how leaders communicate, how they handle challenges, and how visible they are to their teams.  

“People don’t care how much you know until they know how much you care,” Kelley said, underscoring a philosophy that prioritizes trust and connection as the foundation of performance. 

All three panelists emphasized the role of transparency in building that trust. Rather than limiting access to information, the leaders described a deliberate effort to share everything from financial data and operational performance to areas where leadership needed to improve. At Area Ambulance, regular town halls provide a forum for employees to ask questions directly, with no topics off-limits. At the Oklahoma City Fire Department, engagement surveys and open communication channels allow leaders to identify employee concerns and respond in real time. Ultimately, the goal is not just to inform, but to align with those they are leading. 

Defining Standards and Holding to Them 

While culture is often discussed in broad terms, the panelists emphasized the importance of making it concrete through clear expectations. 

At Area Ambulance, that clarity is distilled into a simple but powerful mindset designed to avoid fruitless venting and promote action: “Fix it or forget it.” Team members are encouraged to either take ownership of a problem by finding a solution or to let it go, eliminating the kind of subtle negativity that can quietly erode culture over time. 

More broadly, Zahrt framed accountability not as a punitive measure but as a cultural strength—a call to the standard. In EMS environments, where much of the work happens without direct supervision, that distinction matters. Adhering to a cultural standard becomes the guide that informs decision-making, reinforces expectations, and shapes how individuals respond under pressure. 

Or, as Zahrt put it: “What happens when nobody’s watching is what determines your outcomes.” 

Plum EMS Director of Operations Brian Maloney says his agency puts focus on collaboration and continuous learning to create a culture where employees take initiative and pursue excellence together.  

“We try to create an environment where people feel supported rather than scrutinized,” he said, adding that the result has been improvements in clinical performance, documentation, and patient satisfaction. 

Measuring Culture Like Any Other Priority 

Another key theme of the discussion was measurement. Culture, the panelists agreed, should be evaluated with the same rigor as clinical or operational performance. Chief Kelley said Oklahoma City Fire leverages engagement surveys to track employee sentiment and identify areas for improvement. At Area Ambulance, Zahrt’s team uses structured “people metrics” to assess trust, accountability, and leadership effectiveness. Low scores in areas like trust or accountability are treated as signals, prompting conversations, guiding training, and informing leadership decisions.  

Over time, data measurement and tangible responsiveness reinforce credibility and demonstrate that feedback leads to change. It can also create a culture that people want to be a part of, according to Maloney. 

“In the history of Plum EMS, we’ve only posted to hire for a position once. We’re lucky to have always been fully staffed and if or when someone does resign, we have good quality people in the pipeline,” he said. “It’s one of the things the culture and the people here have created, and I can’t give them enough credit for it.” 

A Continuous Commitment 

Finally, all three panelists agreed that building agency culture isn’t a one-time initiative. It requires ongoing attention, focused on finding ways to connect leadership, teams, operations, and outcomes. 

“There’s no magic recipe,” Zahrt said. “If you’re not proactively driving your culture, you’re going to fall behind.” 

To catch the full panel discussion, you can watch the webinar on demand.  

Advocacy in Action: EMS Day on the Hill 2026

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On March 26, 2026, more than 350 EMS leaders, advocates, and supporters gathered in Washington, DC for EMS on the Hill Day, an annual advocacy event. Members of the Digitech team accompanied agency representatives, spending the day meeting with Senators and House Representatives to garner support for current legislative bills that impact our industry.  

Together, we brought a unified message to Capitol Hill, advocating a slate of legislative priorities designed to modernize care delivery, strengthen the workforce, and ensure the long-term sustainability of emergency medical services. Among the top priorities this year were legislative bills focused on Treatment in Place (TIP), Mobile Integrated Health (MIH) and Community Paramedicine (CP) programs, as well as rural EMS agencies.  

Here are a few highlights of the legislative priorities: 

Treatment In Place and Mobile Integrated Health 

At the forefront of proposed legislation is the Comprehensive Alternative Response for Emergencies (CARE) Act, which would allow EMS providers to be reimbursed for treating patients in place; an important shift toward more flexible, patient-centered care that reduces unnecessary hospital transports while still supporting agency revenue. Despite the demonstrated benefits of such methods, funding remains a roadblock for agencies. One National Association of Emergency Medical Technicians (NAEMT) study found that 38% of MIH-CP programs across the country that had ceased operations over a three-year period attributed their closure to funding, staffing, or resource shortages. In addition to the CARE Act, however, the complementary Community Paramedicine Act would expand Mobile Integrated Healthcare (MIH) programs through federal grants, enabling EMS agencies to play a larger role in preventive and community-based care, particularly in underserved areas. 

Rural EMS Support 

Sustainable funding remains a critical concern for rural providers, particularly in the face of rising costs and increasing hospital closures. According to the National Rural Health Association, nearly 50% of rural hospitals in the United States are operating with negative margins, leaving them vulnerable to closure. When a rural hospital closes, the surrounding communities lose access to vital care, often leaving EMS agencies to fill the gap. Continued investment through Supporting and Improving Rural EMS Needs (SIREN) Act grants would deliver essential resources for training, equipment, and operations to agencies that often serve as the only healthcare access point in their communities. 

Prehospital Blood Transfusion 

Another focus was the ability to administer blood in the field; an increasingly vital practice in rural and outlying communities where transport times to the hospital can stretch or that represent logistical challenges. The improved outcomes and real-life examples of such practices are clear. According to the National Highway Traffic Safety Administration (NHTSA), severe bleeding is the primary cause of preventable fatalities in trauma patients, but with the prompt delivery of prehospital blood, it’s estimated that 37% of trauma patients with severe bleeding could be saved; and that for every minute of delay in administering blood, the risk of death increases by 11%. Yet despite the documented benefits of administering blood in the field, the EMS reimbursement structure hasn’t been updated. The proposed Reimbursing Emergency Services for Critical Use of Emergency Blood (RESCUE) Act addresses this financial gap by ensuring EMS agencies are reimbursed for administering blood in the field, helping expand access to lifesaving prehospital interventions. 

National Recognition and Support 

Finally, EMS leaders emphasized the importance of recognition and advocacy at the national level, first with the Honor Our Emergency Medical Services bill which seeks funds and backing to establish a National EMS Memorial. Similar to our national fire and police memorials, the new memorial would honor those EMS personnel who have died in the line of duty. Continued support for the Congressional EMS Caucus was also emphasized, ensuring these and other industry priorities have a strong, bipartisan voice in Washington to help promote, educate, and increase awareness among decision-makers on the federal EMS policy. 

Together, the initiatives at the center of EMS Day on the Hill 2026 reflected a comprehensive approach to advancing EMS, addressing some of our industry’s key challenges, and laying the groundwork for a more resilient, responsive system of care.

EMS Budget Navigation in Uncertain Times

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How do you budget when there are unprecedented changes occurring? Many EMS agencies find themselves facing this dilemma as their industry navigates various legislative changes with unclear impacts.

And the shifts aren’t stopping anytime soon; there are certain to be additional changes on the horizon.

Let’s consider this:

  • We’re still waiting to see how the impact of the One Big Beautiful Bill Act of 2025 (OBBBA) will impact Medicaid coverage over the next several years, given its 9-year phase-in.  
  • As of early 2026, healthcare subsidies for Affordable Care Act (ACA) insurance plans have lapsed.  
  • Government shutdowns have put Medicare ambulance add-ons at risk; however, on this there is a reprieve through 2027 based on the delayed budget passed in early February.  
  • What, if any, impact the No Surprises Act will have on ground ambulance providers is still pending a decision by Congress.  
  • Cost reporting as part of the initial Ground Ambulance Data Collection System mandate by CMS is complete, but how that data will be utilized by MedPAC, and whether there will be any changes to Medicare allowances at some point in the future, is unclear.  

Then there are state level changes. Many states have passed Ambulance Balance Billing legislation or are considering it. Medicaid Ambulance Supplemental Payment Programs exist in a number of states, but there is uncertainty about how those might be impacted by OBBBA.

Now that our heads are sufficiently spinning, it’s time to step back and take a more prudent approach to planning. There is no doubt that the uncertainty level has increased, but the exact impact of everything occurring isn’t known—and the timeline for the changes to occur is playing out over months and years, not days.

What advice can be given to people or businesses facing this sort of financial uncertainty? Here are four tips.

1. Take a more conservative approach to planning for revenue streams.

For example, if your agency’s revenues have been increasing at an average rate of 5% for the past five years, perhaps it is time to project them to be flat for your upcoming budget year. This will likely be questioned by your stakeholders, but sharing what is known to be happening, such as the upcoming cuts to Medicaid coverage and the loss of ACA subsidies, points to a reduction in patients with medical insurance and more that are uninsured.

Do you want to quantify that? You or your billing partner should easily be able to model the impact of a modest reduction of Medicaid and Commercially insured patients, for example, of one percentage point each by shifting those two percentage points into Self Pay.

By modeling a few tweaks, you accomplish a couple of things: First, you signal to your stakeholders that there is some uncertainty on the horizon. You can explain that the exact impacts are unknown, but that it is expected that there will be downward pressure on reimbursement, all else equal. Second, you start to build some buffer into your budget. If the drop ends up being twice as much as you planned for, the gap would be half of what it would have been if you had not planned for a modest change.

2. Assess possible mitigation strategies

If you believe that there will be downward pressure on your core revenues, now is a good time to look at whether there are steps your agency might be able to take to counteract those reductions.

For example, when is the last time you assessed your ambulance fee schedule? How do your fees compare with other providers in the surrounding area? Even though increasing fees only drives additional revenue from patients with Commercial insurance, it does provide an opportunity to offset reductions due to factors outside of your agency’s control. Is your agency billing for treatment and no transport encounters? Again, this might be something to consider to provide some additional revenue for the agency.

Granted, most options come with trade-offs and require navigating community and political considerations, but by laying out some possibly offsetting actions, your agency’s key stakeholders will appreciate that your team is not just talking about lost revenue without providing some off-setting options.

3. Consider contingencies

It is best to avoid being caught off guard by something that was signaled but not fully foreseen. If you planned for a modest reduction in your patients’ Commercial insurance coverage due to ACA subsidy elimination and it ends up having a bigger impact, what will you consider to offset those revenues losses? Perhaps it‘s as simple as communicating early on with your stakeholders so they can plan accordingly. How about setting up a billing/revenue dashboard and committing to monitoring it monthly in order to detect trends early on?

What if you are forced to offset some of your revenue decreases with expenditure reductions? Start thinking about what might be achievable, and over what timeframe those changes can be implemented. For example, can you tweak your response model to only send an ambulance and not a fire apparatus on low acuity calls? Can you utilize nurse triage to address low acuity calls to avoid having to put another ambulance in service? Can you implement a fee for non-transport calls to discourage callers from viewing an ambulance response as a free service?

Very few approaches can be implemented quickly, so some pre-planning is key. Another valuable approach is to reach out to agencies in your area and regional associations to see what priorities they are considering. You might find areas for collaboration and find ways to open revenue options that can be pursued collectively, such as state-level balance billing legislation which supports provider reimbursement.

4. Advocate your value and needs

Approaching your key stakeholders once you are experiencing shortfalls is often too late. Now is the time to share details such as the high costs related to 24/7 readiness and your community’s demand for rapid response during a medical emergency. This advocacy needs to be at the local, state and federal level as well as with other participants in the healthcare eco-system (e.g., hospitals and insurance companies).

Share your cost data with political leaders and explain how Medicaid and Medicare reimbursement rates typically do not cover your costs. Explain to them why a Medicaid Ambulance Supplemental Payment Plan is so vital or why the GADCS collected data really needs to drive reimbursement reform for Medicare payments. This advocacy can be both for the shortfalls on transports and for the fact that there are numerous calls your agency responds to where patients are not transported and no reimbursement is received from most Payers.

This sort of education could also create pathways for reimbursement options for alternative services such as Community Paramedicine and Mobile Integrated Health. In the end, your agency exists to service your community and all you are asking for is the funding to provide the best care possible.

Whether the number of changes that have occurred over the past couple of years is unprecedented or the new normal, our industry needs to be prepared. This is no different than the preparation that is done for the unknown, next 911 call. We need to be prepared for that urgent/lifesaving call at any moment. We do that clinically by having the right personnel, equipment and training so that we are ready. For budgeting, we need to similarly invest time to be prepared to financially navigate the inevitable changes to our revenue streams.

It is time for EMS agencies to plan for the financial unknown.

No ACA Subsidies? What EMS Providers Need to Plan For

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It’s becoming more likely that a solution or compromise to provide subsidies for lower income individuals to afford Affordable Care Act (ACA) insurance plans through State Marketplace Plans will not materialize. Although the exact impact is unknown, there are estimates as to what the reductions might entail.  

Why does this matter to EMS agencies?

Typically, the highest reimbursement for patients served by EMS agencies comes from those with Commercial insurance plans. If individuals are unable to afford Marketplace insurance without some financial support, they are most likely to become uninsured, and the reimbursement for uninsured patients is only pennies on the dollar. 

Let’s look at some of the early numbers since the subsidies have already lapsed for 2026, absent an unlikely deal achieved by Congress:

  • Per data published by CMS on January 28, 2026, about 23 million people signed up for individual market health insurance through one of the States’ Marketplaces.  

  • Open enrollment ended on January 15, 2026.  

  • The 23 million is down from 2025’s number of 24.2 million or about 5%, which is material but not substantial.

At a glance, it would seem like the revenue impact on any given EMS agency would be modest; however, a big concern isn’t just the 5% drop. Just as important is whether individuals begin to drop out of their plans by not paying their premiums if they find themselves unable to afford the monthly payments. Some third-party industry parties such as KFF have estimated that the ACA Marketplace drop would include close to 2 million people, possibly more. 

For any agency it’s not a simple as saying, “OK, if I plan for an 8% reduction in Commercially insured transports, that will give me a good idea of my at-risk revenue.” This is because some geographic locations have more enrollees than others. If you only look at the top 5 States with Marketplace enrollees, there is some tie to population, but not entirely.

State Marketplace Enrollees (2026 in millions)
Florida 4.5
Texas 4.2
California 1.9
Georgia 1.3
North Carolina .8

Therefore, agencies located in these States would feel more of an impact. Additionally, locality within the State will have an impact. The people most susceptible to dropping insurance are typically lower-to-middle class individuals who make too much money to qualify for Medicaid, but not enough money to comfortably afford their various living expenses. As a result, they’re forced to make trade-offs about spending money on housing, food, healthcare, transportation and various other living expenses. 

How can EMS agencies prepare?

Agencies are going to need to account for this shift in the insurance coverage of their patients. As an illustrative example, let’s use the 8% drop in Commercially insured individuals mentioned previously:  

  • For an agency that does 10,000 transports annually and has 15% of its patients with Commercial insurance coverage, that translates to 1,500 commercially insured patients.

  • If 8% drop out, that’s 120 people.

  • If the average reimbursement for a Commercially insured patient is $1,250 versus $50 for someone without insurance, you could expect a drop of $1,200 for those 120 patients or a $144,000 annual decrease.

  • If your agency is four times bigger, that’s over a half million dollars in reduction.  

You should be able to calculate the possible impact on your agency by asking your billing company to pull your numbers, similarly to above, and provide the impact at various reduced levels. 

As Digitech has been stating for quite some time, we expect most of these impacts to occur gradually versus having an immediate drop; however, over the course of the next year, it is important to pay attention to the trends so that your agency can plan accordingly. 

Perhaps a lifeline will be given to people relying on the Marketplace plans by Congress, but the current uncertainty suggests that a prudent approach is to plan for a gradual decline in revenue from your Commercially insured patients. 

Promise and Pitfalls of MIH in NC: Building Sustainable Community Paramedicine Programs

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Across North Carolina, EMS agencies are expanding their mission beyond emergency response by piloting Mobile Integrated Health (MIH) and Community Paramedicine (CP) programs. These initiatives have the potential to transform community health, reduce unnecessary emergency department visits, and improve patient outcomes.  

Success Story: Durham County EMS 

Durham County originally launched a community paramedics program to follow up with opioid overdose patients, providing them with education, access to medication-assisted treatment and detox centers, and Narcan. Today, they’ve expanded to include fall prevention and vaccines for homebound patients, working via referrals from EMS crews, DSS Adult Protection Services, the Duke Outpatient Clinic, and other sources. 

They also raise an important question: How do you fund and sustain them? 

A New Model of Care for North Carolina EMS 

EMS agencies in several parts of the state — including Durham County and other early adopters — are testing MIH and CP models that extend paramedic care into homes, clinics, and alternative destinations such as mental health facilities. 

Typical services include:

  • Post-discharge follow-ups to prevent readmissions
  • Home safety checks for frequent callers or at-risk patients
  • Vaccinations and chronic condition monitoring
  • Transport to behavioral health or urgent care centers instead of emergency departments

These programs help fill gaps in the healthcare system by using the trusted presence of EMS to reach patients who might otherwise fall through the cracks, driving positive impact for communities, hospitals and public health departments, and most importantly, patients.  

The Financial Challenge: How Do Communities Fund MIH / CP Programs? 

While such initiatives improve outcomes, they often don’t fit traditional billing models. Most payers, including Medicare and Medicaid, reimburse only for emergency transports to hospitals, not for non-transport services or alternate destinations. Even commercial insurers do not consistently pay for non-traditional EMS services, but can be receptive if it better serves their member and saves money. 

That leaves many agencies relying on grants, local funding, or hospital partnerships to sustain their programs. In North Carolina: 

  • There is no standardized mechanism for billing community-based follow-up visits.
  • Payers may not pay for services provided by MIH practitioners (e.g., community paramedics are often not recognized as valid providers of services that advanced level practitioners are approved for).
  • Denials are common when documentation doesn’t align with payer definitions of medical necessity or eligible service codes.

For agencies already stretched thin, the lack of reimbursement clarity can make MIH and CP programs difficult to justify financially, even when their community benefit is clear. For the best shot at building a sustainable model, EMS leaders must plan effectively.

5 Questions agencies considering a CP/MIH program must ask:

  1. What services will your MIH/CP program offer? Options include home follow-ups, chronic disease check-ins, alternative destination transport, behavioral health outreach, frequent user mitigation, and more.
  2. Which payers will you attempt to bill? Check with other providers and associations if your local Medicaid MCOs, commercial carriers, or Medicare contractors have defined codes or contracts for these services.
  3. How will you document and code the service? Determine what visits count as “non‐traditional.” Outline how you’ll track them and capture data needed to justify payment?
  4. Will you have internal financial tracking for cost vs. reimbursement? Model the staffing, vehicles, supplies, oversight, training costs as well as project reimbursement sources so you can forecast the program’s sustainability. Don’t forget to identify cost mitigation.
  5. How will you engage your community and healthcare partners? Form partnerships with hospitals, primary care, behavioral health, public health, and social services by illustrating the value of the services you intend to provide.

Looking Ahead: Aligning Innovation with Sustainability 

North Carolina is one of many states examining a shift toward integrated, preventative EMS care. As agencies across the state evaluate cost-based reimbursement models and supplemental funding options for such innovation, their ultimate success will depend on multiple factors, including clinical excellence, data discipline, and advocacy. By collecting the right data, building strong partnerships, and pushing for payment reform, North Carolina EMS agencies can help to scale and integrate community-driven programs. 

 

Whole Blood in EMS: Lessons in Life-Saving Innovation and Financial Considerations

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Groundbreaking clinical innovation is taking hold in agencies from Georgia to California as EMS providers increasingly carry and administer whole blood in the field. What once seemed like an aspirational extension of military medicine is quickly becoming a realistic option for civilian agencies, bringing hospital-grade trauma care directly into the prehospital environment. 

The positive impact on patient survival rates is measurable. Still, launching a whole blood program isn’t simply a clinical decision. It’s a structural, financial, and organizational commitment that requires coordination at every level. Agencies exploring the idea often find themselves inspired by the lifesaving potential but overwhelmed by the operational and fiscal realities that accompany it. 

Setting the Standard: Ventura County’s Whole Blood Program 

At Digitech’s inaugural Frontlines and Bottom Lines EMS Innovation and Monetization Summit in Costa Mesa, California, presented in partnership with First Due and Bound Tree, attendees heard a firsthand whole blood case study from the Ventura County Fire Department. 

VCFD Whole Blood Program Manager Edward Campana described a multi-year planning process that involved his agency, the Ventura County Medical Center, Vitalant blood donation services, and Ventura’s EMS agency. Together, the stakeholders collaborated to develop cohesive policies, training, and oversight. Crews participated in simulation-based competency evaluations and refrigeration systems were rigorously tested. The program officially launched in April 2025, and to date, VCFD has completed 26 field transfusions with no complications.  

Ventura County’s success is rooted in multiple, mutually reinforcing factors. Every case undergoes interdisciplinary QA review, and quarterly data reviews track usage patterns, reaction rates, wastage, and patient outcomes, allowing continuous refinement of both protocols and training. On a logistics level, cold chain integrity relies on validated refrigeration and strict rotation cycles, while continued education focuses on simulations to ensure readiness for relatively infrequent situations. Future plans include enhanced public messaging to educate community members and promote local blood drives. 

Financial Sustainability: The Reimbursement Factor 

While whole blood programs clearly improve patient survival rates, they also introduce ongoing costs that agencies must be prepared to sustain. The reimbursement pathways for whole blood programs are currently narrow. Medicare allows the use of blood products in EMS to qualify reimbursement from an ALS level to an ALS2 level. Some agencies have begun evaluating adding a supplemental charge to allow additional reimbursement for these expensive products from Commercial health insurers. 

An important aspect of tracking the usage of blood products is standardized documentation templates embedded in ePCR systems. Through specific prompts, responders can support whole blood rationale by linking the intervention to the patient’s clinical condition, vital signs, shock indicators, and reason for transfusion. 

Tracking cost and outcome data is important since there is increased discussion on tying reimbursement to patient outcomes. Given the drastic improvement in patient outcomes when whole blood is utilized in the pre-hospital setting, this is an area EMS agencies can utilize to make the case for additional reimbursement. 

Key Considerations for EMS Leaders 

For agencies considering a whole blood program, the main takeaway is that operational workflow requires a substantial investment, but that investment brings a substantial benefit to trauma patients in urgent need of blood. Ventura County is a prime example of what is achievable when a program aligns clinical infrastructure, hospital and blood bank partnerships, training and QA programs. They are just now beginning to explore a billing strategy that provides some financial support. With these factors in place, agencies are positioned to set new standards in prehospital trauma care while seeking revenue that supports it. 

 

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

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

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

Importance of Accurate Documentation 

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

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

Leadership and Compliance Culture 

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

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

A Growing Priority for the EMS Sector 

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

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

5 Best Practices for the North Carolina Debt Setoff Program: What EMS Leaders Should Know

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You may already be familiar with North Carolina’s Debt Setoff Program. Managed by the NC Department of Revenue, the program allows government-operated EMS agencies (or their billing partners) to recover unpaid transport bills by intercepting state tax refunds or state lottery winnings owed to the patient.  

Why does it matter now more than ever? 

In an environment where reimbursement pressures are constant and in flux due to changing Medicare, Medicaid, and insurance landscapes, programs like Debt Setoff can play an important role in supporting agency sustainability. The recovered revenue can fund operations, equipment, and community initiatives that ultimately benefit the public. 

How does it work? 

  1. Unpaid accounts are submitted to the Debt Setoff Clearinghouse, which matches those debts against state databases. 
  2. If a match is found, a portion of the patient’s tax refund or other eligible state disbursement is redirected to the EMS agency to cover the outstanding balance.
  3. The recovered funds are then transferred back to the agency—creating a low-cost, high-yield method of reclaiming revenue. 

The program offers a low-cost, high-yield recovery option that many North Carolina counties use to reclaim revenue that would otherwise be lost. Several counties have already adopted this approach, successfully recovering thousands in lost EMS revenue each year. 

5 Best Practices for NC Debt Setoff Success 

While North Carolina’s debt setoff process is managed by the state, agencies still bear responsibility for ensuring that participation is ethical, accurate, and compliant. Here are five ways to make sure your agency is optimizing the opportunity in a conscientious and mindful manner:  

1. Follow All Applicable Regulations

Though it’s a government-run process, participating agencies still need to follow both state and federal debt collection regulations. This includes the Fair Debt Collection Practices Act (FDCPA), even if your agency isn’t technically classified as a debt collector.

2. Verify Patient Information Thoroughly

Before submitting a debt, confirm the patient’s identity and verify all relevant account details. Misidentifications or ambiguous terms like “Estate of..” or “Heirs of..” can lead to disputes or delays, so maintaining accurate and well-documented records is key.  

3. Safeguard Patient Data

Submit only the minimum necessary data to the Clearinghouse and use secure file transfer methods with proper encryption. Protecting patient privacy is not just a regulatory obligation; it’s a trust imperative. Send required letters promptly and retain proof of mailing, even if they are undeliverable. 

4. Communicate with Compassion 

Proactively, agencies may publish notices to encourage payments before setoff, which can prompt payments and reduce administrative workload. Once notified of a debt setoff, however, patients can be surprised or even alarmed. They may not have realized they had a remaining balance. To minimize anxiety, use clear, respectful, and empathetic communication to explain the situation, offering support or options when appropriate.  

5. Work with Experienced Partners 

If your agency uses a billing partner or vendor, choose one familiar with NC Debt Setoff Clearinghouse requirements. The right partner can ensure data accuracy, compliant notices, and proper documentation throughout the process. 

The North Carolina Debt Setoff Program represents a smart, compliant, and community-conscious way for EMS agencies to recover outstanding revenue. To learn more about it, visit the state’s website at www.ncsetoff.org. 

 

How California EMS Agencies are Navigating a Changing Reimbursement Landscape

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Digitech’s inaugural Frontlines and Bottom Lines summit in Costa Mesa, California featured a session on The California Reimbursement Landscape. Below are insights from what was a valuable and interactive discussion.

As in many states across the U.S., agencies in California are facing a complex reimbursement environment shaped by federal budget fluctuations, evolving Medicaid structures, and rising concerns about underinsured populations. These challenges aren’t isolated policy shifts; they’re increasingly defining the operational realities for EMS and Fire Service leaders. 

At Digitech’s inaugural Frontlines and Bottom Lines EMS Innovation & Monetization Summit, presented in partnership with First Due and Bound Tree, the California reimbursement landscape emerged as a dominant theme. Lively interactions between our industry expert speakers and attendees whose agencies are living the realities underscored a clear narrative: California EMS is bracing for structural changes in how ambulance services are funded, and the strategies they deploy now may determine their financial stability for years to come. 

Cost Reporting and the Medicaid Gap 

Central to the discussion was California’s approach to closing the Medicaid reimbursement gap. For public providers, Medi-Cal transports often reimburse far below the actual cost of service, shifting financial responsibility to local taxpayers. As such, cost reporting programs like California’s Ground Emergency Medical Transportation (GEMT) model remain one of the state’s most important tools for recovering these losses. 

The GEMT program’s evolution has tracked significant shifts in Medicaid’s structure. At the same time, managed care has overtaken fee-for-service models; California’s adoption of a “Rogers rate” methodology has helped standardize reimbursement expectations across regions and provider types. More importantly, it has streamlined cost reporting, reducing the administrative burden on agencies while preserving access to federal matching funds. 

These developments signal a larger trend: Reimbursement reform that once depended on fee-for-service frameworks is rapidly adapting to the dominance of managed care, forcing EMS leaders to rethink long-standing financial assumptions. 

ACA Subsidy Changes and the “Underinsured” Patient 

Another emerging pressure point is the shifting landscape of the Affordable Care Act (ACA) subsidies. While projections suggest thousands of Californians may lose insurance altogether if federal subsidies are reduced or expire, analysts argue that the more pressing concern may be the rise of the “functionally uninsured” patients; those who carry coverage but face deductibles so high that they cannot meaningfully use it. 

For EMS agencies, this distinction matters. High-deductible plans often translate to unpaid balances and increased collections burdens. As more individuals turn to lower-tier ACA plans to manage rising costs, agencies may see a growing segment of transported patients responsible for 100% of their ambulance bill, an outcome that destabilizes revenue while negatively impacting the patient care experience and placing the financial burden on vulnerable households. 

Federal Changes and GEMT Stability 

Federal policy provisions in the One Big Beautiful Bill have raised questions about the future of supplemental payment programs in many states, including California. However, early assessments suggest that the GEMT structure in California is less likely to face immediate disruption. 

This is because GEMT funds flow exclusively to public providers and are designed to offset the gap between Medi-Cal reimbursement and the true cost of service. As such, the program relies on a long-standing federal commitment to match state expenditures for Medicaid-covered care. Unless that underlying commitment changes, the supplemental funding mechanism should remain intact. For many local agencies, this assurance offers rare stability in an otherwise unpredictable financial climate. 

A Sector Preparing for Structural Shifts 

Overall, the themes emerging from California’s EMS leadership conversations reflect deeper national trends. Cost pressures tied to Medicaid, the growth of high-deductible plans, and fluctuating federal priorities are reshaping how agencies plan, budget, and deliver care. For public EMS systems already operating at the crossroads of essential public health functions and financial constraints, the ability to adapt will be essential. California’s evolving reimbursement strategies, particularly through programs like GEMT, may serve as a roadmap for other states confronting similar gaps. 

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

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

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

1. Complement the Data with Observations

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

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

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

2. Review Narratives for Relevance

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

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

3. Review Narratives for Accuracy

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

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

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

4. Remember: Even AI Can Glitch

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

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

5. Safeguard Legality and Billing Compliance

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

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

The Bottom Line

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

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

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

Three Documentation Practices That Protect Your EMS Agency

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

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

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

1. Verify Crew Signatures and Credentials

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

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

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

2. Train Staff to Proofread

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

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

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

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

3. Obtain Valid Patient Signatures

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

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

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

Bottom Line

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