Many EMS managers are familiar with the concept of benchmarking. Whether used for monitoring and improving financial performance, clinical care or other key areas of EMS operations, the consistent measurement of defined parameters over time can yield critical information for management decision-making. With Medicare and Medicaid audits, investigations, overpayment recoveries and other enforcement activity reaching an all-time high, EMS managers must add a new set of metrics to their tool kit: compliance benchmarking. As with any other type of benchmarking, EMS agencies can monitor critical aspects of billing compliance with specific, measurable performance parameters. The metrics we will discuss below were first presented at the Page, Wolfberg & Wirth Executive
Institute. We call these ―Compliance Performance Indicators,‖ or CPIs for short. Here
are some of the CPIs that your agency can most likely implement immediately within your current software reporting capabilities.
One of the most fundamental aspects of compliance benchmarking is to measure your service mix. This is a CPI that tracks the percentage of ALS, BLS, specialty care transport, emergency and non-emergency calls your agency handles. In recent years, there have been a number of qui tam whistleblower cases and other enforcement actions against all-9-1-1 EMS agencies alleging that they overbilled Medicare for ALS services. These systems deployed paramedics on every call, and then billed substantially all of their calls at the ALS level, believing that the performance of an ALS assessment justified all ALS-level billing.
However, Medicare’s ALS assessment rule first requires that there be a qualifying ALS
-level emergency dispatch (among other things) in order to properly bill for an ALS a
ssessment. In some cases, a full 100% of some agencies’ claims were being billed as ALS emergencies, but Medicare’s own statistics show that the national percentage of
ALS to BLS emergency claims is about 67
33%. So, monitoring your service mix is critical to knowing whether a compliance issue may be lurking in your billing. Other important service mix metrics to benchmark include the percentage of repetitive patient transports, especially dialysis, which are seen as a high compliance-risk area. Also, measu
ring trends in your agency’s performance of discharges from a healthcare facility to a patient’s home could yield helpful compliance metrics, as many audits have
questioned the medical necessity of these types of ambulance transports.
ayer mix is equally important to assessing and improving your agency’s
compliance. Payer mix refers to the relative percentages of Medicare, Medicaid,