Tag Archive for: Fraud

Inherent Problems of Time Saving Set-ups

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Inherent Problems of Time Saving Set-ups

This week ABS Inc. are going to continue the overview of procedural and coding issues faced by Fire Chiefs and EMS services in general, all of which typically lead to investigations, prosecutions and hefty fines.

While many good software programs exist there are others that are not up to the job and cannot assure full compliance to the requirements of Medicare or Insurance companies. The problem comes about when trying to establish settings or default codes in to fields or table tables in the program you are using. They can be time-savers for certain but unless done correctly, will inevitably lead to future issues and cautions needs to be exercised in the billing for the transport provided by ambulance services.

Regulations set out by Medicare show a requirement for answers to a set of questions for each transport, known as an ACR (Ambulance Certification Record). The topics cover are transport type, usage of restraints and condition of the patient when transported, were they in shock or unconscious at the time?

The majority of questions require a simple yes or no answer so departments typically set the defaults to one of these two responses. On the surface that appears to be a reasonable action, so what is the problem here?

If “no” is the default setting it is a good method to avoid fraudulent submission but it can lead to loss of payments for ambulance claims that are valid if the field is not correctly “checked”. Conversely, if “yes” is the default answer, and again the field is incorrectly checked, a fraudulent claim is almost inevitable as you are highly likely to be submitting false claims if the answers do not tally to the patient’s condition.

If you are experiencing any issues with your set up, codes, procedures or ambulance billing contact ABS Inc, we have the answers and solution.

Next week, ABS Inc will conclude this series regarding codes and procedures in the EMS environment, until then have a very merry Christmas.

Poor procedures lead to fraud investigations

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Poor procedures lead to fraud investigations

Having touched on the matter of fee schedules and coding errors, this week ABS Inc. will discuss the procedural errors that also create problems for Emergency Medical Services.

Procedural errors are the most common error for fire departments and are caused mostly due not being familiar with insurance and Medicare regulations with regards to Ambulance transport but as always, Medicare will not accept regulation ignorance as a defense. Medicare also considers information published in the Federal Register, newsletters and carrier billing manuals as adequate billing and charges procedures so the onus is very much on the ambulance services to ensure and up to date copy of their carrier’s manual is in place and further ensure a careful review of the section updates in newsletters.

Fire departments are also somewhat negligent when it comes to submitting claims that are not supported with signature authorization documents, HCFA 1500 & 1491 claim forms. Not only are these claims considered as fraudulent by Medicare and insurance companies, it may also be considered as mail fraud.

If an insurance company or Medicare carrier request a signature authorization form and the fire department cannot produce it, monies made for that claim will almost certainly need to be refunded. If a fire department is audited by a Medicare carrier and it is discovered that it is routine to not provide the forms the carrier is likely to request further investigation at the Office of Inspector General. Medicare has authority to recover monies paid out for each Medicare transport for a period of three years prior to the date of the investigation.

ABS Inc. will continue of the procedural errors next week to highlight further common practices that rebounding on departments create problems, fines and reimbursements that should never have been necessary in the first instance.

Crack the Code

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Crack the Code

Last week ABS Inc. covered the issue of fee schedules and the initial base rate set up for your business, the impact and pitfalls faced by setting it up incorrectly. This week we are covering coding errors.

Insurance companies and Medicare reimburse transportation by ambulance once it has been confirmed the transport was “medically necessary”, based on the condition of the patient when transport was provided and to this end a coding system was been introduced to aid the billing process. Medicare requires claims to be submitted with at least one diagnosis code (ICD Code) as outlined in the International Classification of Disease manual. Since the development of the ICD codes used as the final diagnoses, the use of them in ambulance transport coding is complex at its best, and at its worst, an opportunity for fraudulent claims by departments, knowingly or unknowingly.

Billing staff members require adequate training to be able to interpret run sheets and the correct codes. It can be all too easy to innocently select the incorrect code identifying the patient condition, a code that implies the condition was worse than it was. It is equally possible that billing staff can select a code that is too vague, more often than not just three digits entered for transport justification.

Such coding errors can lead to fines and even the forfeiture of reimbursements. Coding errors are the main reason most fraud investigations take place, and they are avoidable errors! It is also common for insurance auditors and is Medicare practice to review claims to identify possible exaggerations or trends. If they identify something that appears to be questionable, they will follow up and investigate further.

Training individuals sufficiently is both time consuming and expensive and the person providing the education needs to be fully conversant with what they are teaching. This is where companies such as ABS Inc. offer a valuable role in:-

  • Saving you time and money in training costs.
  • Ensuring your base rate is set up correctly.
  • Ensuring the correct codes presented on all claims are correct.
  • Maximizing your reimbursements.
  • Avoiding potential fraud investigations.

Contact ABS Inc. to discuss your needs and find out just how we get offer you the best solution to your EMS billing.

Common Billing Errors

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In the majority of cases where fraud charges have been filed against emergency medical services and fire departments, the problems are normally traced back to their billing process. Unfortunately in these cases, ignorance of the regulations is not valid in defending a prosecution. In order to avoid the possibility of a fraud investigation, EMS managers need to have a clear and thorough understanding of current regulations. A number of common errors have been identified, these common errors are:-

  • Fee schedules
  • Coding
  • Internal Procedures

Fee schedules – In the case of fire departments, this typically relates to the adoption of the fee schedules and structures set out by ambulance services. Billing methods and inappropriate charges are the most common errors.

Coding errors – Insurance companies and Medicare reimburse transportation by ambulance once it has been confirmed the transport was “medically necessary”, based on the condition of the patient when transport was provided. A code system has been introduced to aid the billing process and Medicare requires claims are submitted with at least one diagnosis code (ICD Code) as outlined in the International Classification of Disease manual. Since the development of the ICD codes used as the final diagnoses, the use of them in ambulance transport coding is complex at its best, and at its worst, an opportunity for fraudulent claims by departments, knowingly or unknowingly. Unless billing staff members are sufficiently trained in the interpretation of the information and able to select the correct codes, it becomes possible for an incorrect code to be submitted unwittingly.

Procedural errors – In fire departments, this is the most frequent type of error, typically due to lack of knowledge or understanding of insurance and Medicare regulations with regards to the services of ambulance transport. As far as Medicare are concerned, ignorance is no defense.

Next week ABS Inc. will continue this theme by going a little deeper in to the issues and highlight the importance of their business when it comes to helping you in preventing any potential fraud investigation against your business.

The cost of billing fraud

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The cost of billing fraud

ABS Inc. are going to run a series of blogs starting this week to highlight the importance of getting your billing right – first time, every time. Businesses like ABS Inc specialize in billing services and are in the best position to help you avoid the pit-falls they lay in wait.

Millions of EMS journeys are billed to health insurance companies and Medicare every year across the United States. For larger organizations they are likely employ specialized staff to undertake the work, however for smaller organizations where perhaps a minimal number of staff may be assigned billing duties as not much more than an additional duty to their routine.

In either case, the requirements are exactly the same. Billing is to be in accordance with strict requirements from a number of different agencies with Medicare being the most notable of them. If an organization fails to process their EMS claims, in accordance to the regulations, they become open to the possibility of fraud charges, significant penalty payments and even reimbursement of monies collected.

Healthcare is the currently the federal budgets largest expenditure. The huge number of claims submitted every year by an equally huge number of providers means the field of healthcare is wide open for fraud. It is estimated that the annual cost, due to healthcare fraud, to the United States government is in excess of $100bn! With the size of healthcare expenditure and estimated fraud figures, the United States government is ramping up their investigations in to fraud, looking at all types of providers.

In recent times, it was announced by the Justice Department that Columbia/HCA, the hospital giant, agreed to pay a fine of $745 million for systematically defrauding, over a period of several years, the Medicare program. Although it is not believed likely that an ambulance provider or fire department would be penalized to such a significant extent, it does indicate the government is getting serious in their drive to investigate fraud and eliminating it.

Next week, ABS Inc will highlight the common errors made by billing staff and you then begin to understand better why ABS Inc. are the sensible choice to undertake your EMS billing duties. Contact us to discuss any issues you may have and see what we have to offer to help you avoid breaching any of the many regulations in place today..