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23-We didn't lie, but we didn't tell everything.
Q:
I have questions about the
ambulance service that I used to work for. I feel they were
trying to get us to lie so that they could get paid more from medicare
and medicaid. When we made a run on a
patient, if we found the patient ambulatory on scene, we were asked to
"bypass" this information on our run reports. In other
words, we didn't lie, but we didn't tell everything about the patient.
An example of what we did most was on hospital discharges back to the
nursing home. If the patient was well able to travel by other
means (car, nursing home van) and was able to get up from the hospital
bed and move to the cot, we had to bypass this information. We
would usually state the following: Pt. A/Of x3, skin w/d/pink.
Pt placed on cot, secured x 3, taken to unit." No
mention of patient being ambulatory!
Many times we would go to
on a call, for example, with a patient complaining of abdominal pain.
We might find the patient walking around, telling us they had gas all
day and couldn't get the Doctor to give them anything, so they would
call us to take them to the hospital. We would go ahead and
transport, even if this patient could travel by other means and there
was no need for the ambulance.
As a Licensed Paramedic
service, there were times that our Director would place two Basics on
a unit and send them out for routine transfers (ex-peg tube
replacement).
Many times we would go
code 1, non-emergency to and from a call. Just a routine
transport!
When it came down to
billing time, which all of us medics had to do with each run that we
did, we were ordered to mark that it was a Emergency Paramedic run.
Even if there was not a Paramedic on the truck, even if it wasn't an
emergency run. We were told that we had to show reason for
ambulance necessity, such as show the patient with severe weakness or
abdominal pain. These runs would then be entered onto the
computer, downloaded to Medicare/Medicaid, and they would never
receive a copy of the run report. Basically, what was being done
is that if there was an audit, they wanted to make sure WE MEDICS took
the fall, all because they wanted to receive as much money per run as
possible. In fact, our Director had a meeting with all of us
Medics and told us that it must be done this way, because we needed
all the money we could get so that she could pay us and keep the doors
open.
I was a Basic at the time.
I quit that job, took my Paramedic test and passed, and went to a
different service. Here, I have learned that if they have a
stubbed toe, this does NOT require ambulance transport. Before,
we transported ANYTHING and got paid good for it.
I am afraid that somewhere
down the line, we Medics who were told to "bypass" pertinent
information in order to get paid better will go down for something our
Director ordered us to do. It was basically a do it or you are
out of here thing. What can I do? I don't want to get in
trouble and lose my licensure over this, and I don't want to be
charged for criminal offenses that I really had no choice in.
Please note, Medics did not do any of the downloading of the billing.
That was done by the Director and the Administrative Secretary/Billing
clerk.
Any assistance would be
greatly appreciated.
A:
I
would believe that you and your coworkers in an environment such as the
one described are headed for trouble.
Therefore, let's begin using exerts from your letter.
1) I have questions
about the ambulance service that I used to work for. I feel they were
trying to get us to lie so that they could get paid more from Medicare
and Medicaid.
When services of this nature are rendered to a patient and the
provider knows, or should reasonably should have known that the serviced
will not be paid, the provider must inform the patient of this fact
in advance and the patient must sign a from acknowledging that they
understand this. The patient is not liable for any unpaid balance: no
attempt can be made to collect this balance according to HCFA. There is
specific language that should be used for this form, and it is best that
it is part of the patient's medical record.
2) When we made a run
on a patient, if we found the patient ambulatory on scene, we were asked
to "bypass" this information on our run reports. In other
words, we didn't lie, but we didn't tell everything about the patient.
An example of what we did most was on hospital discharges back to the
nursing home. If the patient was well able to travel by other means
(car, nursing home van) and was able to get up from the hospital bed and
move to the cot, we had to bypass this information. We would usually
state the following: Pt. A/Of x3, skin w/d/pink. Pt placed on cot,
secured x 3, taken to unit." No mention of patient being
ambulatory!
What you were being asked to do, and have apparently agreed to do, is to
knowingly omit data about the patent's medical condition in an effort to
influence decisions on reimbursement, by two major agents of the Federal
and State government. I would also note that I suspect that this
practice is universal in your agency. I believe your actions also
involve omitting essential health data t the staff at the receiving
facility should have in order to accurately assess the patient's
clinical status in an effort to promote the fiscal needs of your agency.
Such actions may constitute negligence on the part of the provider, and
the agency, as it is apparently an accepted practice. I also question
the ethical nature of your conduct.
3) Many times we go to
on a call and encounter a patient complaining of abdominal pain. We
might find the patient walking around, telling us they had gas all day
and couldn't get the Doctor to give them anything, so they would call us
to take them to the hospital. We would go ahead and transport, even if
this patient could travel by other means and there was no need for the
ambulance.
This situation is not unlike those we discussed above. Explain the
possibility that the serviced may not be covered in which case, the
patient may be responsible for any balances due. That often stops any
further arguments. However, if it doesn't, then take the patent to the
hospital and gat on with it
4) As a Licensed
Paramedic service, there were times that our Director would place two
Basics on a unit and send them out for routine transfers (ex-peg tube
replacement). Many times we would go code 1, non-emergency to and from a
call. Just a routine transport. When it came down to billing time, which
all of us medics had to do with each run that we did, we were ordered to
mark that it was a Emergency Paramedic run. Even if there was not a
Paramedic on the truck and even if it wasn't an emergency run.
In the past, HCFA reimbursement for ALS vs. BLS was based on the type of
unit sent, not the medical necessity for the type of unit sent. To
further improve the potential to receive reimbursement, providers were
told to show a reason for ambulance necessity, such as severe weakness
or abdominal pain. These runs would then be entered into the computer,
and billed electronically to HCFA. This will all be changed in the new
HCFA reimbursement structure that should be in place by next year. Now
would be a good time to change, unless the Director simply wants to
squeeze every last drop of money available from the system. In addition,
as I alluded to in item 2, these actions probably violate a number of
regulatory standards established at the State level and one might
question whether this agency's licensure status should be revoked.
5) Basically, what was
being done is that if there was an audit, they wanted to make sure WE
MEDICS took the fall, because "they" wanted to receive as much
money per run as possible. In fact, our Director had a meeting with all
of us Medics and told us that it must be done this way, because we
needed all the money we could get so that she could pay us and keep the
doors open. However, if it makes you feel any better, HCFA and
Medicaid will be crawling all over your Director long before they get to
you. This is a classic deep pocket issue and you and you fellow medics
are hardy the deep pocket, particularly if a settlement is reached in
lieu of trial. (You may run afoul of the State regulators since they
have few if any fiscal authority over agency operations).
Yours sounds like so many
of the situations that exist in the EMS industry today. I believe your
decision to leave was timely. However, bad management practices
promulgated primarily by an unethical management staff, the need to make
ends meet does not relieve providers of their ethical obligation to
protect the rights of their patients and compliance with applicable
regulations and laws related to EMS.
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24-
Shift Alternatives?
Q:
What a great site you have!
As a brand new EMS manager I'm looking into all
possible scenarios with regard to the most popular types of shifts that are used nationally. Presently our Medics are on 24 hour shift but are on
call for the latter 8 hours of any given 24 hours shift. I'm not particularly happy with this system and am exploring every aspect and alternative.
Presently we have 4 full time units with 19 full-time medics on hand/2 medics per unit. We also have a good number of part-time available when
needed. Of course it goes without saying that our county administrators want overtime cut so I'm trying find out what other EMS managers are up to.
Can you help???
A:
If you wish to continue to use some form of 24-hour shift pattern, you could
adopt a 2-day workweek as I suggested to a previous individual. This will
reduce random overtime to some degree. Otherwise, you have exhausted your
options if you wish to continue to use these shift patterns. Using 12-hour
shifts might also reduce overtime but will reduce the level of compensation
employees have come to expect. Even mixing medics with EMT basics provides
only limited savings.
Selecting the number of hours to be worked and the shift pattern to be used
may lend itself to an employee "vote" of sorts, not because they are
"popular" but because employees may have insights management does not fully
recognize. At the same time, staffing and scheduling decisions have fiscal
consequences that employees may not understand, or prefer to ignore. So, let's not let these get out of hand. Then there are demand data that have
not been provided. Is it possible that you are overstaffed? Good
questions. I would be happy to follow these with you as you study your
options.
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