Common Mistakes With Self-Pay Billing


Common Mistakes With Self-Pay Billing

By Patrick J. Mannix Sep 25, 2017

When it comes to EMS billing, no two providers are alike. Cookie cutters don’t exist in the ambulance industry—each business is unique. For example, even though there are five main commercial healthcare insurance payers across the U.S., each state and region reports nuances in coverage, processes, requirements and reimbursement rules.

To further complicate ambulance billing issues, self-pay populations carry their own payer variations and operational challenges. Across the 17 different states and hundreds of EMS providers supported by my company, Andres Medical Billing, two common mistakes with self-pay billing have emerged: capturing incorrect patient demographics and trying to bill the wrong payer.

Mistake #1: Incorrect Patient Demographics

Having incorrect patient demographics is almost as frustrating as having no contact information at all. For many ambulance trips, the patient doesn’t have identifying information at the time of transport. And following the transport, attempts to obtain correct demographic information from the hospital’s emergency department or billing personnel often fail. Given these realities, finding correct demographics for patients who are uninsured at the time of transport is a critical first step in solving EMS billing woes.

The benefits of taking time to obtain correct demographics outweigh any billing delays due to the extra effort. These include:

  • Lower billing costs when up-to-date demographics for self-pay patients are available;
  • Reduced operational billing expense—up to 20%—with fewer wasted or returned mailings;
  • Greater staff efficiency since billers are not required to track down demographic information, make phone calls, send faxes, etc.;
  • Increased cash flow due to timely and correct insurance claim filing for patients without coverage.

Mistake #2: Wrong Payer or Ineligible Coverage

When insurance isn’t available, the provider may quickly bill the wrong party instead of taking time to find an active, eligible payer. And when coverage is available, limitations are common. For example, some policies cover only hospital, dental or vision—not EMS services. Guesswork is often used in lieu of proper insurance discovery and verification.

The adage “haste makes waste” holds true in self-pay EMS billing. Claims sent to incorrect or ineligible payers delay reimbursement and increase billing costs. Rejections and denials must be worked by already-overstretched staff, creating further declines in productivity, efficiency and morale. The process takes time and money.

The Value of Clean Data in EMS Billing

For both demographics and active insurance coverage, EMS providers reduce billing costs and expedite cash flow when they take measures to ensure clean data. The process typically involves submitting electronic lists to an eligibility clearinghouse and waiting for a response.

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However, recent technology integrations enable real-time demographic verification and insurance discovery, with results automatically imported back into EMS systems’ billing workflow. Billers minimize redundant data entry and toggling between systems. The result? Timely filing of claims to payers and faster reimbursement for services covered by insurance.

The ability to pull up clean data as part of the initial billing workflow, versus waiting a few days for a vendor response, further substantiates the value of checking first, billing second. Once you have the right data, every other step in the billing process becomes easier—even for self-pay patients.

Here are five results achievable for EMS provider clients by using a real-time, integrated approach to demographic verification and insurance discovery:

  • 20% reduction in overall billing costs;
  • 10% more coverage found;
  • Faster reimbursement from payers for any patient covered by insurance;
  • Increased cash flow;
  • Improved staff efficiency through automation and access to clean, correct data.

What Lies Ahead for EMS Billing

With new options for coverage emerging every day, along with greater flexibility through Medicaid expansion, EMS providers often find up to 10% active and eligible coverage for self-pay trips. Coverage is out there. And discovery is worth the time.

Shifts in the individual market coupled with ACA uncertainty will continue to drive annual patient plan changes and increased movement of coverage into managed care contracts. Frequent transitions in coverage are seen across all payers—including Medicare. Keeping up manually is no longer an option.

Despite ongoing talk about healthcare change, the industry has seen little progress so far. As the debate continues, more volatility is expected across all components of the EMS billing process. Ensuring clean data will help EMS providers transition quickly—regardless of which way the tide shifts for national healthcare reform.

Patrick J. Mannix is CEO of Andres Medical Billing in Arlington Heights, Ill. E-mail him at

Andres Medical Billing
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