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Raising the Reimbursement Bar

   This month, we speak to prominent EMS attorneys Doug Wolfberg and Steve Wirth, of the leading EMS law and consulting firm Page, Wolfberg & Wirth ( Wirth's 2010 EMS World EXPO presentation addressed building critical documentation skills, while Wolfberg delivered a Medicare reimbursement and compliance update. Here we discuss their presentations in more detail.

   Steve, let's start with documentation. What kinds of skills do people need to build or improve?

   Wirth: You need to do more than just clinical documentation. You need to integrate the operational side with the reimbursement side in addition to the clinical documentation. We try to bring those things together. Operational stuff can be anything from things you observe at the scene beyond specific patient care to general demographics, response times, those kinds of things.

   One of the problems is that folks sometimes have difficulty in creating a picture of what's going on with the patient. If you're reading the report, you should be able to visualize what was going on with the patient at the scene, even if you weren't there. When Medicare reviewers look at claims, they look to see if there was a narrative that created a picture describing the patient's condition, and particularly why they needed to go by ambulance.

   What kinds of strategies and techniques do you share to help people document better?

   We use examples--actual narratives from patient care reports we've seen, where we'll show the actual narrative statement as written by the EMT or medic, then we'll explain some of the pitfalls of that documentation and how it can be improved. We try to show the good and the bad, if you will.

   Has the move to electronic documentation improved this at all?

   It's helped a lot. Most programs integerate the field documentation with the billing software, so it avoids a lot of duplication down the road in the billing process. It's made it easier for folks in the field to prepare the documentation, because they can use portable devices. But to some extent there's been an overreliance on some of the pull-down menus and check boxes and things that come with electronic documentation. In some areas we've fallen away from just writing good reports that create a good picture of what's going on.

   Doug, what kinds of changes will healthcare reform be bringing to the Medicare process?

   Wolfberg: One of the things that's starting to become fleshed out a bit is the movement toward provider productivity, and these so-called productivity adjustments, which could have a negative impact on ambulance reimbursement. Another piece will be changes with some of the legislation that's trying to make permanent some of the temporary increases in adjustments in the healthcare reform bill. Those increases are scheduled to expire in December.

   The productivity adjustment--a payment reduction based on the idea that systems get more efficient over time--is new to our industry. What's the threat of that?

   They're now going to annually adjust reimbursement rates based on two factors: one is inflation, and one is the productivity adjustment. This year's [inflation] adjustment was negative, but they did not decrease reimbursement. The productivity adjustment can be applied to actually result in a decrease, based loosely on the assumption that providers will get more efficient as these healthcare system changes are implemented.

   There's a lot of talk about greater scrutiny on Medicare waste, fraud and abuse--and on overpayments that result from simple mistakes. Are you seeing that among your ambulance clients?

   Yes, significantly. That's probably an even bigger impact than the reimbursement changes. You never want to see negative reimbursement changes, but we're talking about a couple percent here and there. The increased enforcement of the fraud and abuse laws has the potential to just be devastating to the industry, even to providers who do things soundly but are careless. Generally the fraud and abuse laws have not been applied to mere mistakes in billing, but now we're seeing an eroding distinction between intentional fraud and maybe just sloppy billing or inadequate understanding of the nuances of the rules. Zealous enforcers are trying to make fraud cases out of those where, in the past, they might not have existed.

   From a compliance perspective, having every I dotted and T crossed; accuracy in coding; doing internal claim audits; refunding overpayments when you detect you've received them--all of those things are now more critical than ever.

   Wirth: We'll cover a lot of that in detail in the full-day workshop too. We'll be hitting very hard on those fraud and abuse changes and what services can do to stay out of trouble. We expect to have a good turnout for that one.

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