Funding Your Future Establishing Fee-for-Service Programs in Non-Profit EMS Agencies

Funding Your FutureEstablishing Fee-for-Service Programs in Non-Profit EMS Agencies Central Shenandoah EMS Council in partnership with: Virginia Office of Emergency Medical Services

Billing for Services is Not New • But it is new for you – • Number of agencies billing in Virginia has increased dramatically in the last ten years. • Experience is the best teacher – Especially someone else’s experience • This is an opportunity to see what others have learned. Central Shenandoah EMS Council and the Virginia OEMS

Who Thinks We Should Bill? • Joint Legislative Audit Review Commission (JLARC) 2004 Report on Emergency Medical Services “Emergency medical service agencies should actively consider billing patient’s health insurance polices for the services and transportation provided.” Central Shenandoah EMS Council and the Virginia OEMS

Who Thinks We Should Bill? • Citizens Groups – Who want an alternative to tax increases to improve services. • Local Governments – Who are continuously being asked to do more with less funding. • Our Staff Members – Who want to do a good job for their community – but don’t have adequate resources Central Shenandoah EMS Council and the Virginia OEMS

Funding Your Future • Section 1 – Is Billing For You? • Section 2 – Implementation • Section 3 – Marketing • Section 4 – Results Central Shenandoah EMS Council and the Virginia OEMS

Part I – Is Billing for You? • A. Define the Problem • B. Reimbursable Services • C. Look at your Community • D. Build your Team • E. How Much Does the Solution Cost? • F. Make a Decision Central Shenandoah EMS Council and the Virginia OEMS

Define the Problem • What will the funds from billing enable your agency to do? • Increase Staffing • Decrease Response Times • Replace Equipment • Citizens what to know where the money will go - If you don’t give them something better will they support Fee-for-Service? Central Shenandoah EMS Council and the Virginia OEMS

Terminology – it all means the same thing • Billing for service • Reimbursement program • Fee-for-service • Revenue recovery • Seeking payments from insurance carriers for benefits that individuals have as a part of their existing policies Central Shenandoah EMS Council and the Virginia OEMS

Reimbursable Services Ambulance Transport Fees • Generated for the care and transportation of ill and injured persons. • Federally sponsored health care insurance programs (Medicare and Medicaid) • Most private health insurance policies have a medical transportation benefit. Central Shenandoah EMS Council and the Virginia OEMS

Reimbursable Services Rescue Service Fees • Submit claims to auto insurance carriers Fire Service Fees • Send to homeowner and allow them to submit to insurance company Special Service Fees are Frequently Rejected by Insurance Carriers Central Shenandoah EMS Council and the Virginia OEMS

Look at your Community • What is the potential financial impact for your agency? • Revenue is related to call volume • How many ALS? BLS? • Who is the Patient’s Insurance Carrier? • Medicare • Medicaid • Private Health Insurance • No Insurance Central Shenandoah EMS Council and the Virginia OEMS

Look at your Community • Who within the community will help you present the concept to the public? • Local Government Officials • Hospitals and Physicians • Community Leaders Central Shenandoah EMS Council and the Virginia OEMS

Build Your Team • Committee Membership • Each Local Government • Each Hospital or a Community Physician • Press Relations – Marketing • Community Representative • Agency Leadership Central Shenandoah EMS Council and the Virginia OEMS

Build Your Team • Committee Goals • Identify Problem • Determine Root Cause of Problem • Identify Contributing Factors • Provide Potential Solutions Central Shenandoah EMS Council and the Virginia OEMS

Build Your Team • Committee Goals – Example 1 • Problem • Slow Responses Times M-F Dayshift • Root Cause • Inadequate Number of Personnel • Contributing Factors • Loss of Manufacturing Jobs – Everyone works out of Town • Potential Solutions • Fee for Service – to provide Supplemental Staffing Central Shenandoah EMS Council and the Virginia OEMS

Build Your Team • Committee Goals – Example 2 • Problem • Difficulty Recruiting and Retaining Volunteer Staff • Root Cause • New Volunteers Aren’t Interested in Joining Agency with • Antiquated Equipment • Inadequate Support of Educational Needs • Contributing Factors • Traditional Fundraising not Adequate to Support Squad • Potential Solutions • Fee for Service – Provide Funds for Training and Equipment Central Shenandoah EMS Council and the Virginia OEMS

How Much Does the Solution Cost ? Project Cost = Billing Revenue OK Project Cost > Billing Revenue NOT OK Closely Match Anticipated System Improvement Cost with Anticipated Patient Revenue Central Shenandoah EMS Council and the Virginia OEMS

Make A Decision • Will the community benefit from planned improvements to the EMS System? • Does the estimated revenue match the cost of the improvements? • Does the committee support the concept of billing? • YES, YES, YES – You have what is necessary to proceed Central Shenandoah EMS Council and the Virginia OEMS

Make A Decision What if the answers are Yes, No, and We Don’t Know? • Reevaluate Community EMS Needs • Seek to Promote Understanding and Gain Consensus • Explore Other Options Central Shenandoah EMS Council and the Virginia OEMS

Part II – Implementation Plan • A. Make An Announcement • B. Obtain Governmental Support • C. Nuts and Bolts • D. Fees and Policies • E. Insurance Carriers • F. Forms & Flow of Information • G. Revenue and Cash Flow • H. Compliance – Records and HIPAA Central Shenandoah EMS Council and the Virginia OEMS

Make An Announcement Letter – notify each group represented on the billing exploration team • EMS Agency • Local Government • Hospitals Central Shenandoah EMS Council and the Virginia OEMS

Make An Announcement Press Release – Issued by Committee Chair and Agency Leadership • Newspapers • Radio • Television Be Sure to List Follow Up Contact Information Central Shenandoah EMS Council and the Virginia OEMS

Obtain Governmental Support • Resolution of Support “We Think This is a Good Idea Too” • Creation of an Ordinance “We Formally Authorize You to Do This” Central Shenandoah EMS Council and the Virginia OEMS

Obtain Governmental Support • Resolutions are Easy to Change • Ordinances are More Difficult • If your local government is involved in setting rates – ask that they set rates using a resolution rather than an ordinance. Central Shenandoah EMS Council and the Virginia OEMS

Internal Billing System Collecting Patient Data Billing Staff Billing Software Dedicated Phone Forms and Postage Interact with Insurance Companies Collect, Post and Deposit Payments External Billing System Collect Data Package Information and Forward to Billing Service Deposit Payments It is easy to see why so many agencies chose to use a billing contractor Nuts and Bolts Central Shenandoah EMS Council and the Virginia OEMS

Pay Per Claim Flat Fee Per Claim No incentive for accuracy or follow-up Percentage of Net Receipts Incentive to work with patients and insurance companies to receive payments Most agencies pay on a percentage of net receipts basis Nuts and Bolts Central Shenandoah EMS Council and the Virginia OEMS

Setting Fees and Establishing Policies • Fees – base on Medicare Fee Schedule • Don’t set fees low now and hope to increase them later. • Maintain your fee schedule. Review charges at least annually. • Policies – focus on fairness • All patients who are transported are billed • Establish definition of poverty or medially needy Central Shenandoah EMS Council and the Virginia OEMS

Membership Programs • Agency accepts a fee as a form of pre-payment for deductibles and non-covered charges. • You agree to accept whatever insurance benefits are paid as payment in full. • Labor Intensive • Membership Revenue should equal what is written off due to the agreement. Central Shenandoah EMS Council and the Virginia OEMS

Relationships with Insurance Carriers • Medicare – pays 80% of allowable charge. Balance due from co-insurance or individual • Medicaid – pays less than 50% of actual charge. No patient billing permitted • Private Insurance Carriers – payment is highly variable. Patient responsible for remaining balances Central Shenandoah EMS Council and the Virginia OEMS

Relationships with Insurance Carriers • Obtaining Provider Numbers – Your agency must be a recognized provider of service • In order to bill federally sponsored healthcare programs • Also some private insurance carriers • Each insurance carrier will have an application process and require copies of various documents Central Shenandoah EMS Council and the Virginia OEMS

Relationships with Insurance Carriers • In Virginia there is a legal requirement that all ambulance providers be paid directly by insurance carriers. It is no longer necessary to become a participating provider in order to receive payments directly from the insurance company. Central Shenandoah EMS Council and the Virginia OEMS

Development of Forms What must be collected for the billing process? • Patient Information • Insurance Information • Clinical Impression / Preliminary Diagnosis • Consent to bill patient’s insurance carrier • Authorization to release medical records Central Shenandoah EMS Council and the Virginia OEMS

Flow of Information • Collect data following transport • Verify that information is complete • Prepare documents for delivery to billing contractor • Establish schedule for timely delivery Central Shenandoah EMS Council and the Virginia OEMS

Revenue and Cash Flow • Revenue • Checks arrive at billing contractor and patient accounts are credited • Checks are deposited by either contractor or agency. • Cash Flow • It takes approximately 12 months to achieve stable cash flow – don’t spend too quickly Central Shenandoah EMS Council and the Virginia OEMS

Compliance & Records • Compliance • Even if you use a billing contractor, your agency is still responsible for complying with all laws, rules, and regulations. • Records • Clinical and billing records are your property and must be maintained. Be sure to recover your records if you change billing services Central Shenandoah EMS Council and the Virginia OEMS

HIPAA • All staff members need to receive HIPAA training. • Provide patients with information on how your agency protects their sensitive information. • Enter into business associate agreements with other entities as necessary in order to legally share information Central Shenandoah EMS Council and the Virginia OEMS

Part III Marketing the Program • A. Common Themes • B. Target Audiences • C. Opportunities to Share Information • D. Providing a Walk Through • E. Dispelling Rumors Central Shenandoah EMS Council and the Virginia OEMS

Common Themes • There are problems with the current EMS system that need correcting • Traditional sources of revenue aren’t adequate to correct the problems • Ambulance billing is a way to obtain resources using insurance coverage that most citizens already have. Central Shenandoah EMS Council and the Virginia OEMS

Common Themes • Services will be rendered regardless of a patient’s ability to pay • The billing process will be sensitive to those who don’t have the financial resources to pay their bill Central Shenandoah EMS Council and the Virginia OEMS

Target Audience • Agency Personnel • Our goal has been and always will be to provide the best possible service to the people we serve • Funding sources that we have relied on in the past are no longer adequate to meet community needs • We intend to preserve the volunteer system by alleviating volunteers from fundraising and supplementing current staffing where necessary Central Shenandoah EMS Council and the Virginia OEMS

Target Audience • Agency Personnel (continued) • Providers must be trained to answer the public’s questions or properly direct their concerns • They are the day to day face of your agency • Create a short list of the most common questions they may be asked and train your providers to answer these questions • Give providers a handout with the answers to these questions and contact information for people that have more information about the BFS process Central Shenandoah EMS Council and the Virginia OEMS

Target Audience • Local Government Officials • Our agency has a long tradition of working with local government to service the public in an efficient and reliable manner. • We understand that it is difficult to shift tax dollars from other programs. • Billing will enable our agency to use insurance benefits that most citizens already have to fund improvements to the local EMS system Central Shenandoah EMS Council and the Virginia OEMS

Target Audience • General Public • When a medical emergency occurs our focus is on responding promptly and providing the best care possible. • This care, however, comes at a cost and traditional funding sources are no longer adequate. • We will continue to respond to all calls for assistance and provide care regardless of a patient’s ability to pay. Central Shenandoah EMS Council and the Virginia OEMS

Opportunities to Share Information • Press Releases • Be sure to provide a consistent message and provide contact information for follow up questions • Public Meetings • Hold meetings where the general public can come and ask questions. • Speakers Bureau • Offer Speakers to Community Groups - Kiwanis, Ruritan, Garden Club Central Shenandoah EMS Council and the Virginia OEMS

Providing a Walkthrough • An emergency occurs and someone calls 911 • An ambulance is dispatched • EMS personnel arrive, the patient is treated and transported to the hospital • The patient signs a form giving the agency permission to obtain his or her insurance information and file a claim with their insurance carrier. Central Shenandoah EMS Council and the Virginia OEMS

Providing a Walkthrough • The signed consent form, the insurance data, and a copy of the patient report is forwarded to the billing service. • A claim is filed with the insurance carrier. • The patient is notified of any remaining balance after payment is received from the insurance company. • All statements from the agency will have a telephone number for questions or if additional information is needed. Central Shenandoah EMS Council and the Virginia OEMS

Rumor Loss of Community Support – Some personnel feel that community support for the agency will decrease due to billing Response Most billing programs produce up to 10 times more revenue compared to fundraising. Agency may consider eliminating or reducing fundraising if billing is successful. Dispelling Rumors - Staff Central Shenandoah EMS Council and the Virginia OEMS

Rumor Loss of Community Support – (continued) Response With strong public education, citizens will continue to recognize the important work that you do in the community Dispelling Rumors - Staff Central Shenandoah EMS Council and the Virginia OEMS

Rumor Increased Work for Field Personnel – Additional paperwork will consume lots of staff time and take staff away from responding to calls Response Billing paperwork requires less than ten minutes per patient. Crews are already completing the pre-hospital patient care report Dispelling Rumors - Staff Central Shenandoah EMS Council and the Virginia OEMS

Rumor No Money = No Response Response We respond to all calls for assistance and provide care and transportation without regard for the patient’s ability to pay Dispelling Rumors – Public and Officials Central Shenandoah EMS Council and the Virginia OEMS

Funding Your Future Establishing Fee-for-Service Programs in Non-Profit EMS Agencies