Improving Collections Archive

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. 

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.