Per C.M.S.: “$687.5 Million in ClaimDENIALS to Ambulance Services.
57.3% of Denials are Due to Bad Data: “Insufficient documentation.” What could your agency do if it got all the money it is due?
2.7% of REJECTED claims had “NO documentation” at all.
2.3% of REJECTED claims were “incorrectly coded.”
Isn’t getting paid for the work you’ve done one of the key tasks that an ePCR is supposed to accomplish?
Here is the basic math. Check for yourself below (sources cited in footnotes):
15.5% of claims went unpaid due to errors, and 57.3% were due to “insufficient documentation,” which amounted to $687.5 million in 2017
According to the NEMSIS TAC, there were 4.02x as many “Treated & Transported 9–1–1 Response” calls in 2019 than in 2017; and 4.32x as many total events.*
If the proportion of denials stays consistent between 2017 and 2019 (and there is no reason to believe they would not, since documentation practice has remained largely the same — or arguably gotten worse as agencies push back on validation strictures)— then the Mobile Medical industry can anticipate that it will MISS OUT on between $2.76375 and $2.970 BILLION (i.e., $687.5 x 4.02 and 4.32, respectively) in 2019.
*NOTE: The proportion stated above and estimated growth in transports and other calls is based on the # of agencies reporting to NEMSIS, shown below. CMS may have visibility on a larger number of agencies that NEMSIS due to differences in reporting requirements by state. NEMSIS v3.X went live in 2013. Even if the figure in 2017 is unusually small — it appears to be an anomaly in terms of reporting to NEMSIS — nevertheless the point remains: $1 billion is still a lot of money to forego for work already done and costs already incurred.
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Table of Call Volumes (2009–2019), per NEMSIS TAC:
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What could your agency do with its cut of between $2.75 and nearly $3 BILLION (2019 estimate) for work that you have already done, but for which charting was so porous that CMS rejected the claims for one or more of the reasons stated below?
In 2017, plenty of EMS and Fire agencies were investing both time and money in ePCR systems, many of which they still use today. What were those systems doing if they were giving up so much money? EMS billing firms are hard-hit as well: they can only bill for what they receive, and if they are receiving Garbage In, then GIGO principles apply. They are hamstrung in their ability to maximize returns on behalf of their client agencies, and by extension, they miss out on potentially tens of millions of dollars as well.
Most importantly during #EMSWeek 2020, our industry is talking about the need for raises and better benefits. (I found your money!!!) Unlike other areas of public health and safety, medical transport services submit bills to insurance, including the Center for Medicare & Medicaid Services (CMS). CMS is explicitly telling our industry that the majority of Mobile Medicine agencies did not report enough accurate details to prove (as every business must) the value of their operations…or even to validate their claims and requests for compensation. This report on the CMS memo is not about any specific firm. Indeed, 57.3% is a solid majority, so one might assume that any or all ePCRs that were widely deployed in 2017 are implicated in the shortfall to some degree.
When is the last time your agency checked in on its payment vs. rejection rate?
What would happen if you sat down with your billing company and asked whether the ePCR is costing money — not only in terms of cash for software and time to document (after all, “free” isn’t free)…but it terms of actually keeping you from getting paid all you’re due?
Could your ePCR be hurting you?
“Put it in the narrative” is not working, obviously— (and this author considers that advice to be outdated)— because a substantial source of CMS rejections is due to incorrect coding. Coding, however, does not go in the narrative. CMS is looking for appropriate discrete values (even though the narrative might be helpful when it comes to recollection in a court, and is an excellent place to tell the story of how one practiced medicine). The C.M.S. memo shown below offers black-and-white proof that trading “quality” for “pretty” when it comes to data is a Devil’s Bargain — and highlights once again that “free” software isn’t free if it costs more in labor than it returns in revenue (or if it even reduces your total return).
The question is: Do Mobile Medical professionals see their data (ePCR) as the key to getting paid for their work — and even getting the raises they deserve — or do they view documentation as futile busywork that supplies statistics to the black hole of state data repositories while ultimately returning no benefit?
CMS’s memo answers that question definitively: It invites agencies to get paid some $700 million more — for work already done — if only they provide the required details. Making the process seamless is a matter of software design.