(4 min read) Dispatch protocols are critical for complying with Medicare rules and maximizing legitimate reimbursement from the largest ambulance payer. Whether or not your dispatch center is using them, your billers or third-party billing agency should be using dispatch protocols when analyzing trip reports and preparing Medicare claims for reimbursement.
In an Ideal World
The goal is to match the resources you send out to the needs of your patients and then get reimbursed for the services you provided. Ideally, dispatch protocols are in place to establish which response is most appropriate for each condition. Then based on the patient condition that is reported to dispatch, the appropriate response — Basic Life Support (BLS), Advanced Life Support (ALS), emergency, or non-emergency — is sent to the patient.
For example, if a caller reports a patient trip-and-fall incident with an injury to a non-dangerous body area and dispatch protocols in your system define that incident as a BLS – Immediate response, a BLS crew would be dispatched to respond right away.
The Reality in Many EMS Systems
Many EMS systems, especially many rural and super-rural jurisdictions, don’t have dispatch protocols. Even if an EMS system does have dispatch protocols, often, the protocols don’t match the resources to the patient because of the EMS agency’s staffing structure and limitations.
For example, in many urban areas, EMS agencies respond to all calls immediately with an ALS crew because that is how they are staffed. Even if a caller reports a minor fall and an injury to a non-dangerous body area, an ALS crew would respond right away — although a BLS crew (if available) could treat the patient.
This practice results in overutilization of resources and can expose all ALS response agencies to compliance risks when billing to Medicare.
Medicare is the biggest payer for nearly all EMS agencies. Medicare defines an emergency response as a 911 call or an equivalent, deploying an immediate response in which the ambulance service takes the necessary steps to respond as quickly as possible. Medicare rules state that it must be reasonable for the dispatcher to issue an emergency response based on the nature of the call.
Whether a transport can bill Medicare as an emergency or a non-emergency is determined before the patient encounter and at the time of call intake. Medicare reimburses emergency transports at a higher rate, due to the increased cost of readiness associated with emergency responses.
Let’s say an ambulance is dispatched for a scheduled patient pickup at a nursing home. When the crew arrives, the patient is in cardiac arrest and is transported to the hospital. Despite the emergency condition encountered on scene, the transport must be billed to Medicare as a non-emergency because at the time of dispatch, the call was a scheduled, non-emergency transfer (with a lower associated cost of readiness).
Conversely, let’s say a call comes in as a cardiac arrest, but the patient’s actual condition on scene is acid reflux, a non-emergent condition under the agency’s dispatch protocols. This call can still be billed to Medicare as an emergency if a medically-necessary ambulance transport occurred because at the time the call came in, it was an emergency (with the higher associated cost of readiness).
Developing Dispatch Protocols
Whether or not your agency has control over dispatch or plans to change the way it responds, developing dispatch protocols for use in your billing office or by your third-party billing agency can improve compliance and increase billing accuracy. Billers can use these protocols to match what happened on the call to the proper level of Medicare reimbursement.
If you don’t currently use protocols, you can start with obtaining a commercial dispatch product, or you can create your own protocols from scratch. Regardless of where you start, you must customize your protocols. Even commercially available products are not intended to be used as-is.
When determining the appropriate response based on patient condition, remember that there are four levels of service to consider for purposes of Medicare billing:
- 1. ALS Emergency
- 2. BLS Emergency
- 3. ALS Non-Emergency
- 4. BLS Non-Emergency
Don’t fall into the trap of defining all ALS conditions as emergencies and all BLS conditions as non-emergencies. There are ALS conditions that might not require an immediate response, and there are BLS conditions that require an immediate response.
Finally, have your agency’s medical director review and approve your protocols, and then share them with your billing agency or billing staff so they can be utilized to determine the proper level of service for billing. Using dispatch protocols will likely increase legitimate revenue and enhance compliance for your agency when billing Medicare.