PWW EMS Law Monthly Tip of the Week–“We Use a Billing Company. We Don’t Need a Compliance Program, Right?”

Wrong.

Many ambulance services use an outside company to handle their billing and reimbursement issues. Some decide that the billing and reimbursement rules are just too complicated to stay on top of. Others would just as soon not have to deal with the whole billing issue. Those are perfectly valid reasons to use one of the many excellent ambulance billing companies that are out there. However, just because you “farm out” your billing, it doesn’t mean you can just “wash your hands” of the whole affair.

Far from it, actually.

Ambulance services, fire departments and other EMS organizations that utilize the services of outside billing agencies have the same responsibility as providers that bill in-house to ensure that their reimbursement and business practices are in order. After all, whose name is on that Medicare claim? Your ambulance service’s. Whose provider number is on that bill? Your ambulance service’s. Who receives the money when the patient or his insurer pays? Your ambulance service. And, if improper billing is found, guess who has to repay that money? That’s right — your ambulance service, not your billing company!

There have been many Medicare audits, False Claims Act cases and other legal actions brought against ambulance services over the years where their defense was simply, “we don’t pay attention to the billing – we use a billing company and just send them our trip sheets. They do the rest.” That’s never a defense. The ambulance service, under the law, must know if the claims that are being submitted in its name are accurate, truthful, complete and supported by the documentation. They must identify any overpayments or improper reimbursement they receive. They must ensure that they are properly billing for the services that were actually rendered. They must ensure that the proper codes are used and proper amounts billed.

Every ambulance service that bills — whether they use an outside billing agency or do their billing in-house — should have an effective, working compliance program in place. That program should, at a minimum, include:

  • A written compliance plan;
  • Periodic internal claim reviews supplemented by periodic outside, independent audits;
  • Written policies and procedures, such as a Code of Conduct, a Background Screening policy, and others;
  • A designated compliance officer; and
  • Many other elements.

The ambulance service should also ask its billing company about the kinds of compliance policies that they have in place, and whether the billing company has a formal compliance program in place as well. The OIG has even issued a separate “Compliance Program Guidance for Third Party Medical Billing Companies.” Is your billing company aware of these guidelines? Do they follow them?

The ambulance service and its billing company should be partners in compliance, making sure that important compliance issues don’t slip through the cracks. There should be a thorough written agreement in place between the ambulance service and the billing company that clearly sets forth each party’s responsibilities toward compliance. The agreement should contain language that will ensure an open channel of communication and that, among other things, sets forth their responsibilities and obligations in the event of a Medicare audit. The billing company should provide feedback and information to the ambulance service, in the form of regular reports or otherwise, on the status of their accounts. And, perhaps most of all, billing companies should be cooperative, and not defensive or equivocal, when the ambulance service decides to internally audit or review a sample of claims, or bring in a consultant to perform a claims review.

Courtesy of Page, Wolfberg & Wirth, LLC

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