My concern is that patients who should go by ambulance may refuse aid because they don't want to get a bill? I hate to bring up money when trying to persuade people to get into the back of the ambulance. Another concern is that if we don't ask the patient to sign, and their chest pain turns out to be indigestion and their insurance won't pay, am I in violation of the law? To ensure compliance, should I ask every patient to sign? Do we have to memorize the list of complaints that are reimbursable. Does the Guru have some words of wisdom?

A:
While I am not sure what "new law" you refer to, it's good you are now in compliance with "old law". HCFA has long required that patients be informed that they may be liable for unpaid claims when the provider knows, or could reasonably be expected to know, that services were not covered. The same
requirement should be anticipated when the claim is denied for lack of medical necessity. To achieve compliance, a statement that advises the patient of this risk can be incorporated into the Authorization for
Release of Information and Assignment of Benefits language that every agency
is, or should be, using for HCFA claims. In essence, one release form for all activities, and signature should be required for all patients. Under ideal conditions, it should be signed prior to or at time of transport.
Provisions exist for patient unable to sign, but think about it: too sick to sign, medical necessity. OK, let's press on. Using one form, a copy of which I suggest should go the patient or responsible party when practical,
the agency can reasonably expect to be in compliance with any requirements
for reimbursement, and any regulations related to patient confidentiality and/or release of information. Failing to have this form signed is not the "violation of the law". Trying to collect without it is the violation in question. HCFA was out to protect the patient from companies "persuading" patients to use a service or a product they knew was either not
covered or not needed, and then turning around and trying to collect after the fact. Failure to have the form signed may not, in itself, prevent the ability to bill the patient, but it makes for a great challenge in today's
"consumer oriented health care system"

There are several challenges to implementing this policy. In cases where the patient's condition is non-emergent, hospitals and long term care facilities have traditionally requested ambulance because the "doctor ordered it", or have used the well known "the patient doesn't have any other way to get home". While the physician was required to document the reason for use of an ambulance, this "certification" has often bordered on,
or was outright, fraud (by both the physician and the EMS agency that then used the
form to bill). Future compliance with HCFA guidelines will stringently require that the physician certify that the patient cannot travel
safely by any other means based on a reasonable standard of medical necessity.
EMS agencies will need to be aware of what services are covered, primarily in terms of origin and destination, and standards for medical necessity.
HCFA has these fairly well defined, and these standards should be adequate for virtually everyone. These must be communicated, in writing, to all health care facilities and providers, notably physicians, though personally I would be more inclined to count on nurses and discharge planners to oversee
this issue. EMS providers, though many believe they are above all of this dirty
work, have a role in insuring that standards for medical necessity are followed, and in accurately documenting the patient's condition. For what most people refer to as EMS response, the situation is in many ways
more clear. First of all, most patients will be transferred to an ED.
Rarely is this a non-covered destination. Second, the "prudent lay person" provisions
of recent federal legislation makes a retrospective challenge by a third
party payer based on lack of medical necessity more difficult, though we
must keep the managed care people in mind. But, at the end of the day, to protect everyone's interests, get the form signed.

To finish this up: there is something troubling about the idea of a provider who "persuades patients" into the back of their ambulance, avoiding the issue of cost to facilitate that goal. Don't worry, everything will be all
right, we are from EMS, and we are here to help. Four weeks later, bang, I get a bill for $453 dollars for riding on your stretcher after you told me I should go to the hospital and get "checked out", even though I was
walking around. Thanks for your concern. That's why this regulation was established, to protect me from you. EMS costs money, so why don't we all stop trying to pretend it doesn't. 

On the issue of cost and access:
there are no data to support the conclusion that costs are a barrier to EMS access
for patients who experience a perceived time critical and/or life-threatening situation. In contrast, national data indicates that
50% of the persons who summon EMS do not need emergency care. That's an access
problem: too much access. And the final point, if cost were a barrier to access, which of the following is most likely to deter use of the emergency health care system: the $300 ambulance bill, the $3,000 ED bill or the
$30,000 hospital admission? You seem like a pretty bright person. You figure this one out. And get the form signed.

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9- Who Reports to Who?

Q:
We are a 99% volunteer agency running 24/7 - 65 members, 3 ambulances for a small city of 30,000. During the day - 7 AM to 3 PM, Mon thru Fri -we have a single paid member. The paid person is also a volunteer -and was a volunteer before s/he took the day paid position.

Here's our management problem - aside from the inevitable politics/ego/territorialism inherent in volunteer agency, s/he feels that during the day s/he is only answerable to the municipality. S/he pretty much reports to a bureaucrat with no medical training. This gives her/him an opportunity to occasionally, "zing" the corps officers s/he doesn't like.

We are currently trying to convince the city that s/he should be managed by the corps officers during his paid daytime hours.

Do you have any opinion?

A:
My take on this is based on certain assumptions that may not be exact, but I think we can begin to move toward resolution. 

First, and foremost, let's clarify this "paid staff" and volunteer thing one more time. You cannot have an individual on your staff that is an employee and volunteer at the same time in the same or similar capacity. Based on what you said, you have a wage employee (paid by the hour or should be) in a full time capacity (40 hours per week) that also "volunteers". Under the strict interpretation of
FLSA, their volunteer hours are hours worked and they are due overtime compensation for these hours, particularly of there is any requirement that they volunteer that could be deemed coercive. I have seen one strategy that I believe could have prevailed on this issue if challenged, but I am having trouble figuring out why you have paid staff in the first place (65 volunteers and 30,000 people!!!) 

In any case, if you can develop a well-structured job description based on your agency's needs and you really think you need one employee, hire an employee. Its quick, clean and it's the law. The secondary benefit of this decision will be to eliminate any misconceptions among the "paid staff" about their status in the agency. Did I mention that conduct that impugns or otherwise jeopardizes the integrity, image or reputation of the agency, its officers, and/or its staff is grounds for immediate dismissal, at least in every policy manual I ever wrote.

Your second problem also seems  self-inflicted. You want this person to be "managed" by the "corps officers". How many corps officers does it take to "manage" one person, or put another way, how many egos do you think one poor employee can put up with? If you have a clear written description of an employee's duties and responsibilities, and you hire individuals who are capable of performing these duties, a whole lot of "management" is not required. What "corps officers" call management is usually little
more than their predictable (not inevitable if they are properly selected) insistence
on micro managing every detail of every event right down to linen change.
This can be restrained by well-developed agency policy and sound organizational structure. In an organization such as you describe, I suggest that paid staff largely report to a single individual, preferably at
one of the more senior levels. Spend the time required to develop your organizational structure and your policies and tell the "corps" that unless the employee is engaged in some behavior that constitutes an immediate
threat to the agency's survival, they should raise their questions and concerns with the designated officer. If they just can't get their egos under control, dismiss them. They can come back upon reaching maturity.
Now to the municipality. If you are a private organization (not-for profit, etc) I am unclear as to why you must "convince" a government official to let you manage your agency as you deem appropriate. In any event, get your new agency policy manual, your revised organizational structure, and your sharpest folks, then put on a presentation for your governing Board, with attendance by "interested parties" (such as local bureaucrats and their bosses). It's serves to put everyone on notice that things are under control (in other words, mind their own business). Be prepared to deal with the all the "politics/ego/territorialism" that you have already noted exists in advance. You cannot afford dissent. Somebody seems to believe
you can't manage your agency in a professional manner and you don't agree. Only one of you can be right. 

I would then suggest you begin to formally define the relationship you have with your local government, clarifying the expectations (and limits) that exist for all parties. Volunteer agencies are, in my experience, death to commit to such a prospect, but if you want the ability to manage your own affairs without the kind of outside interference you are currently getting, everyone needs to know the rules and then play by them. In the end, everyone's interest, including your community's, will be better served. As an aside, if your local "bureaucrat" runs from this like a scalded dog, he knows the jig is up. It's my guess you will probably not hear much from him in the future, particularly once he doesn't have "an ear". If you are a governmental agency of some sort, you still have to go through the same process. How you position yourself in the City bureaucracy is something I can't comment on without seeing it up close and personal.

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10- Pay and 'Garcia Law'

Q:
We are a organization that the local county government pays a tax subsided and technically are owned by the county but we are managed by a privately owned hospital and are paid by the hospital. We work 24hrs on and 48hrs off. Do we still fall under the Garcia law because we are technically employees of the privately owned hospital? If we don't fall under that law how do they have to pay working 24hrs or don't they have to pay?
The hospital right now is throwing around the idea of paying straight time trough the night instead of overtime. Can they do that?
Where is the best place to get a copy of the Garcia law?

A:
Garcia was not a law but a ruling regarding the applicability of certain aspects of the Fair Labor Standards Act, specifically overtime compensation, in the public sector. The case involved the issue of whether an employee of a municipality could "volunteer" and be paid for the performing the same function for the same political jurisdiction. The impact of the ruling on public safety was primarily in terms of fire fighters, (and similarly EMS personnel) who held full time paid posts and also volunteered in their same community. If you have Internet access, information can usually be found via most search engines and I also think it is at the Department of Labor site. But the issue does not apply to you, as you are a paid employee of the hospital. No private sector employee can "volunteer" and be paid to perform the same duty. Nothing new here. Therefore, let us move on to your other questions.

For persons working 24-hour shifts, there is a sleep provision in the wage and hour laws for ambulance services. Up to 8 hours can be excluded from pay. If the employee is "relatively undisturbed" for no more than 3 hours that time (you get up and run one call), then the employee is paid only for those hours worked. If the employee is up more than 3 hours, all 8 hours are considered time worked and must be paid. This is a pain to deal with for employer and employee alike, and unless it is a serious question of money, I do not recommend using this exclusion. Regarding time paid for 24-hour shifts, the wage and hour laws for ambulance services state that all
hours worked over 40 in a week must be paid at time and a half. It doesn't matter when you work them. Hours cannot be averaged between work weeks, defined as a set of seven consecutive days. Therefore, for an employee on 24/48, if paid for all hours on duty, is due 40 hours straight time and 8 hours overtime for two weeks, and then in the third week is due 40 hours of straight time and 32 hours of overtime (three shifts at 24 hours each). I have always supported the use of K Days in the third week, reducing each employee back to two shifts. The employer can pay straight time wages to one  additional full time employee and instead of overtime for both members of a two-person crew (7 FTE instead of 6).

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