The Nuts and Bolts of Northampton EMS

With Shore Memorial set to move north, the role that emergency medical services will play in the future will be critical for the citizens of Northampton County. The County will be expecting our EMS to either provide urgent medical care, or taking the patient to the next, closest healthcare facility. Of note, all Northampton ambulances are equipped with twelve (12) lead acquisition and transmission capability, which allows for on‐scene diagnosis of ST‐elevation myocardial infarction (STEMI) or severe heart attack. Hollye Carpentar’s EMS staff is trained in the use of this equipment. With work on the current budget proceeding, funding for EMS is once again a hot button issue. While the Emergency ADHOC committee has recommended for some time that there would need to be an increase in the EMS budget, the request to for an increase this year has raised some questions. We also realize that most folks do not have a firm understanding of how the complex system of services provided by county staff and volunteer services commingle to create a countywide network of emergency services. We started by asking a few basic questions of the County Administrator staff Janice Williams and EMS director Hollye Carpenter.

Last year we had over 4,000 calls, and from those calls, $120,000 went into the general fund as a result of ambulance billing. Is the rest distributed to the volunteers EMS agencies?

A total of 2842 EMS calls were answered in FY2015. Approximately 70% of the calls resulted in a transport to the hospital. Only transports are billable/insurance collectible. Northampton County only bills for those transported in ambulance 31-1 which was a total of 226 calls. The volunteer agencies bill for calls transported in their ambulances. Of note, the volunteer agencies collect and keep the fees for their organization; those fees do not go back into the general fund. $139,243 went into general fund for ambulance billing for FY15. Included in this amount are billing moneys received for 31-1 transports and funds received from Cape Charles Rescue Service and Community Fire Company for some additional night and weekend staff which equates to just under $45,000 each per year.

How are transport services accounted for (is there a breakdown of costs)?

Note: Each of the volunteer agencies also bill for services and have their own billing policy. Recently they moved to using the same billing company as NCEMS and they are working towards the same billing rates.

What are the actual expenses for each part of the operation?
NCEMS budget for FY16 consists of the following: $1,235,459 for personnel (salary and benefits), $105,395 for operations and $73,178 for grant funded capital purchases. Each volunteer EMS agency (Community FC, Northampton F&R & Cape Charles RS) has their own budget and operational costs. This information will need to be acquired from them.

Is there a rationale for having insurance reimbursement and individual “gap” charges being commingled in the General Fund when released to the County?

Ambulance Billing Revenue is included as county income through a “charge for services” line item. This income amount is quite small as compared to the overall budget for EMS services. I am not sure why it should not be included as part of the General Fund.

How do we handle the accounting and billing of EMS transport (who, which department)?

Each transport agency uses a third party vendor for accounting and billing of EMS transports. Cornerstone Adminisystems is currently the vendor used by all four.

What are the billing parameters?
(1) A bill will be generated for ambulance services conducted by all county owned and/or county permitted ambulances utilized by Northampton County Department of EMS. Fees collected will be used by the Northampton County Department of EMS to provide emergency medical services staffing and expenses related to the provision of EMS.
(2) Patients will fall into one of the following categories for billing purposes:
a. Insured, county resident “in good standing”. For the purposes of ambulance billing, “in good standing” means all county taxes are paid in full. Only the appropriate insurance carrier will be billed.
b. Insured, county resident “delinquent”. For the purposes of ambulance billing, “delinquent” means all county taxes are NOT paid in full. The appropriate insurance carrier will be billed and then a bill for any unpaid fees (i.e. deductibles and co-pays) will be sent to the patient transported or responsible party.
c. Insured, nonresident. The appropriate insurance carrier will be billed and then a bill for any unpaid fees (i.e. deductibles and co-pays) will be sent to the patient transported or responsible party.
d. Uninsured county residents. A bill will be sent to the patient transported. If the individual or responsible party has the ability to pay, then payment is expected in full. If the patient can demonstrate financial hardship in accordance with the Compassionate Billing Policy, they may qualify for waiver of fees.
e. Uninsured nonresidents: A bill will be sent to the patient transported. If the individual or responsible party has the ability to pay, then payment is expected in full. If the patient can demonstrate financial hardship in accordance with the Compassionate Billing Policy, they may qualify for waiver of fees.
f. Internal services: (1) If an employee of the County is injured while working for the county and requires ambulance services, these services will be classified as worker’s compensation expenses until deemed otherwise by the County’s Worker’s Compensation Insurance Carrier. If the worker’s compensation claim is denied, these expenses will be re-billed to the employee directly or through their private insurance as outlined in Items a-e, above. (2) If an Inmate of the Eastern Shore Regional Jail requires medical transportation, the regional jail is responsible for the bill. The commonwealth will be billed for the transports of state inmates in the judicial system.
g. Contractual write-offs: The bills that Medcaid, Medicare, and insurance companies pay on behalf of an insured individual are sometimes adjusted to pay only a portion of the billed amount. This adjustment referred to here as “contractual write-off” is usually due to the laws governing the payment amount or through agreements between the insurance companies and billing entity. The contractual write-offs are not considered unpaid balances, and will not be billed to patients.

What percentage of transports are just unnecessary “taxi service” to the hospital?

We do not delineate transport in the manner. We are not allowed to refuse transport, and we are required to transport to a hospital Emergency Department. Almost all calls are received through 911 and everybody’s emergency is different.

Is there a list of individual charges not covered by insurance and not being honored with payment?

Receipt of insurance payments is based on necessity, documentation, contractual allowances and deductibles. Also there are some individuals who do not have insurance. There is nothing specific that is not being paid, however minimal “self pays” are received. “Self pays” include those without insurance or who have applicable deductibles.

What action is used to get payment not honored?

I. Compassionate Billing Policy(1) No one will be denied necessary medical service due to either their inability to pay or a lack of insurance.
(2) All consumers of ambulance services will be asked, in writing, to provide information regarding available insurance coverage. All consumers or ambulance services may receive written notification of the value of services received and notice of billing forwarded to their insurer(s).
(3) Compassionate billing is intended to eliminate or minimize out-of-pocket expenses for ambulance services received by county residents. The county regards taxes paid by our residents as inclusive of co-pays and/or deductibles for ambulance services for all persons living in a taxpaying household. Elderly or disabled residents qualifying for real estate tax relief pursuant to county ordinance shall be deemed qualified for relief from any deductible or co-pay for ambulance services received.
(4) Any resident lacking health insurance may submit a waiver request form stating a financial hardship. No personal banking information or tax form copies will be required as proof; the good faith statement by the resident regarding household income level will suffice. Persons showing household income below fifty thousand dollars ($50,000.00) shall qualify for waiver of fees based on hardship.
(5) Northampton County’s billing company will not pursue payment recovery through a debt collection agency without express authorization of the county administrator or his/her designee.
(6) If any insured party requires EMS services within a calendar year that exceeds their policy limits and no additional insurance coverage is available, the fees for service beyond coverage limits will be waived.
(7) If the insurance company deems the transport is not medically necessary the billing company will verify the information that was submitted to the insurance company and resubmit the claim for reconsideration. If the insurance carrier still deems the transport not medically necessary the county administrator or his/her designee will review the individual case for possible waiver or the fees.

II. Billing and Collections
Billing and collection services will be provided by a billing contractor. No county EMS personnel will accept or receive payment on behalf of a patient. Payments may be made at the Northampton County Treasurer’s Office. Any inquiries regarding billing or collection procedure will be referred to the billing contractor, or to designated personnel of the Northampton County Department of EMS.

The volunteer agencies also utilize a soft billing program.