RE: Refusals and transports

[Guest guest]

You're generalizing that too much. Insurance companies can read the

narrative, so even if you list the nature of the call as SOB, if your

narrative states that the patient was SOB because they just ran 6 miles

while being chased by the local PD, the claim can be denied.

Re: Refusals and transports

None, but as far as I know your insurance company CANNOT deny an EMS

transport claim when the reason for the call/transport is classified as

SOB. Talk

about liability-on the part of the insurance company...

[Guest guest]

You're generalizing that too much. Insurance companies can read the

narrative, so even if you list the nature of the call as SOB, if your

narrative states that the patient was SOB because they just ran 6 miles

while being chased by the local PD, the claim can be denied.

Re: Refusals and transports

None, but as far as I know your insurance company CANNOT deny an EMS

transport claim when the reason for the call/transport is classified as

SOB. Talk

about liability-on the part of the insurance company...

[Guest guest]

It could go with anything, lets take away the asthma and put in a 2 "

laceration to the arm, you care for the bleeding which is neither venous

nor arterial. Bleeding is controlled. In other words, your patient is

VERY stable. You place a 4 X 4 and some Kerlix around it, and convince,

or scare, or intimidate (pick your poison) the patient into going to the

hospital because they may need sutures.

Sutures are not an immediate need, but since you insist that they go

with you, they reluctantly agree.

The insurance company denies payment, who pays?

Re: Refusals and transports

What precipitated your attack? Why couldn't you treat it yourself? What

if

you go into status asthmaticus because one breathing tx isn't enough. I

think,

it'd be too risky for insurance to deny...

[Guest guest]

It could go with anything, lets take away the asthma and put in a 2 "

laceration to the arm, you care for the bleeding which is neither venous

nor arterial. Bleeding is controlled. In other words, your patient is

VERY stable. You place a 4 X 4 and some Kerlix around it, and convince,

or scare, or intimidate (pick your poison) the patient into going to the

hospital because they may need sutures.

Sutures are not an immediate need, but since you insist that they go

with you, they reluctantly agree.

The insurance company denies payment, who pays?

Re: Refusals and transports

What precipitated your attack? Why couldn't you treat it yourself? What

if

you go into status asthmaticus because one breathing tx isn't enough. I

think,

it'd be too risky for insurance to deny...

[Guest guest]

Missing the point, fact is, insurance companies can deny claims, even if

the nature of the call was CP or SOB, based on the contents of the

narrative, unless you delve into fraud in the narrative.

From: cllw602@...

Then you treat 'em, and turn them over to PD. But just like the drunks,

they

have the option to go by you or go by PD, most go with us. Besides, you

ever

noticed most pt's on the run from the law don't have insurance?

[Guest guest]

Tom,

That's exactly the point that Wes was trying to make.....

From: FireMedic1633@...

>>The insurance company denies payment, who pays?

>>Unfortunately the patient. Why would you talk someone who is

otherwise in >>a nonurgent situation into riding in an ambulance? I

would only transport >>them if they insisted.

>>Tom LeNeveu

>>Learning Paramedic

[Guest guest]

Wait, lets get back to the call at hand, lets keep them separated, we

are not talking about a CP patient who required NTG, we are talking

about insurance companies denying claims for patients who did not

require ambulance transportation.

A patient who had a 2 " laceration on the arm, bleeding was controlled.

No complications, nothing at all.

Insurance will pay that???? No way!!! If they do, I REALLY want to read

the narrative.

I base my treatment plan on what I see and what I learn, but there is a

lot more to it than that, after I observe and ask questions, that's when

my critical decision making process comes in, if you don't utilize any

decision making process, you tend to be practicing 'cook book' medicine.

What if your CHF patient does not present with classic signs of CHF? How

do you know what to treat? Through a decision making process that will

ultimately lead you to your own 'opinion' of the patient's crisis.

That, according to Webster's, is a diagnosis.

Main Entry: di.ag.nose

1 a : to recognize (as a disease) by signs and symptoms

Re: Refusals and transports

Are you going to write on your run form that you felt all the pt needed

was a

breathing tx or a spray of NTG, and no transport?

Write what you see, what they tell you, not what your opinion is...

That's not fraud.

[Guest guest]

As one who's relatively experienced in billing.... the only time the

insurance company sees a narrative is if we appeal a claim that wasn't

initially paid. The only time run reports are routinely sent with the

initial claim is with Medicaid. That is their requirement. Claims are paid

off of the ICD-9 codes (diagnosis) which are tied to the reason for

ambulance. Charges for the claim are paid based 'reasonable and customary'

charges for the services provided.

Medicare is phasing in a fee schedule, and is reportedly moving away from

utilizing ICD-9 codes in favor of 'Condition Codes'. These will be used to

determine not only if a claim is to be paid, but at what level (BLS vs ALS,

Non-Emergency vs Emergency). Look for insurance companies to follow suit

in establishing fee schedules for EMS.

Jack Pitcock

Baytown Health Dept EMS

RE: Refusals and transports

Missing the point, fact is, insurance companies can deny claims, even if

the nature of the call was CP or SOB, based on the contents of the

narrative, unless you delve into fraud in the narrative.

[Guest guest]

Actually... they do.

No narrative sent... just the ICD-9 code for laceration to the arm.

Jack

Re: Refusals and transports

Are you going to write on your run form that you felt all the pt needed

was a

breathing tx or a spray of NTG, and no transport?

Write what you see, what they tell you, not what your opinion is...

That's not fraud.

[Guest guest]

Let me add a couple of items to Wes's scenario. Other than payment, what are

at least two other major considerations that come into play when making

transport decisions?

a.

b.

Further, what part does your documentation play in the insurance

company/medicare/medicaid's decision to pay or not to pay?

Mr. Grady,

Colleague and Gadfly to Hs. Honorable Esquireship, Dr. Ogilvie

In a message dated 3/29/2004 7:12:58 AM Central Standard Time,

ExLngHrn@... writes:

I see your points. I'm just trying to provoke or foster a little bit of

discussion on whether transport is always necessary.... and the potential

pitfalls

that could result from " steering " a patient one way or the other regarding

transport. The standard is INFORMED consent. That means being a patient

advocate

and giving them the appropriate information to make the proper decision.

-Wes

[Guest guest]

I hate to burst the bubble on this but I have YET to see an insurance company

pay an treat and street claim (on scene treatment and no transport). If you

don't take them to the hospital, they don't typically pay a dime even though you

used supplies and equipment to treat the patient.

Jane Hill

----------

[Guest guest]

Jane,

We've actually received a few insurance payments recently on no transports.

It's only been recently and only a few, but it sure surprised me when we got

the first one. I don't know why this has suddenly started happening--we've

made no changes in our documentation methods, and are using the same billing

agency that we've used for years. I can only guess that maybe some of the

insurance companies have realized that sometimes it's cheaper to pay for

scene treatment than to pay for EMS treatment and transport plus ER/hospital

care. It would stand to reason that an insurance company might consider

scene treatment by EMS to be similar in nature to an office visit to the

doctor. Whatever the reason, I'm glad to see that at least a few no

transports are being paid.

Maxine Pate

hire-Pattison EMS

----- Original Message -----

> I hate to burst the bubble on this but I have YET to see an insurance

company pay an treat and street claim (on scene treatment and no transport).

If you don't take them to the hospital, they don't typically pay a dime even

though you used supplies and equipment to treat the patient.

>

> Jane Hill

>

>

[Guest guest]

I am anxiously awaiting that one on my end. I know that Medicare WILL pay a BLS

pickup no mileage if the patient is deceased and has not been pronounced prior

to EMS arrival, but even they only pay that intermittently and with no

consistency. I DO think it is time for insurance companies to start to

acknowledge that treating a patient that requires minimum treatment that can be

provided by EMS without transport by EMS DOES save them money when it is

indicated and NOT against the standard of care. But very few have acknowledged

this to date... Maybe more in the future...

Jane Hill

----------

[Guest guest]

We've seen something else recently that is new and intriguing in the way of

payment from Medicaid. A payment we received today is an example: The run

was in October, 2003--pedi, respiratory distress. Of the initial claim,

Medicaid had approved only the charges for gloves, and sent us $3.90 payment

(their approved portion of that charge). Today we received additional

payment. Medicaid has now approved the rest of the charges, and sent us

payment for their approved amount, minus the $3.90 already paid of course.

We've had this happen on several Medicaid claims recently--usually just the

gloves, sometimes gloves and oxygen, initially paid, and then the balance

later. It looks like they are initially approving what we could have

reasonably been expected to use at the scene, as part of the assessment and

scene care, while they are still reviewing and making a detemination on the

transport. As far as I can recall, these have all been on runs where the

patient was transported rather than on no-transports. Just another thing

that makes me go " Hmmmmm " . In the past it's always been all or nothing, so

this is an interesting change.

Maxine

hire-Pattison EMS

----- Original Message -----

> I am anxiously awaiting that one on my end. I know that Medicare WILL pay

a BLS pickup no mileage if the patient is deceased and has not been

pronounced prior to EMS arrival, but even they only pay that intermittently

and with no consistency. I DO think it is time for insurance companies to

start to acknowledge that treating a patient that requires minimum treatment

that can be provided by EMS without transport by EMS DOES save them money

when it is indicated and NOT against the standard of care. But very few

have acknowledged this to date... Maybe more in the future...

>

> Jane Hill

[Guest guest]

Jane:

The issue is the type of policy and coverage the patient has. Bare bones

policies like HMO's and PPO's seldom pay the no transports fees and consider

them not medically necessary. They have told me that the patient could have

gone to his/her primary care physician if the problem did not require

transport. Many of the more expensive policies pay for ALL emergency charges

at 100%. I would always try to bill for no transports and fight for payment.

P. Naughton

Assistant Chief

Shavano Park FD/EMS

15604 NW Military Hwy.

San Texas 78231

Cellular

_____

From: je.hill@...

Sent: Monday, March 29, 2004 15:25

To:

Subject: Re: Refusals and transports

I am anxiously awaiting that one on my end. I know that Medicare WILL pay a

BLS pickup no mileage if the patient is deceased and has not been pronounced

prior to EMS arrival, but even they only pay that intermittently and with no

consistency. I DO think it is time for insurance companies to start to

acknowledge that treating a patient that requires minimum treatment that can

be provided by EMS without transport by EMS DOES save them money when it is

indicated and NOT against the standard of care. But very few have

acknowledged this to date... Maybe more in the future...

Jane Hill

----------

[Guest guest]

Are you talking about TREATMENT no transports?

Jane