In a prepayment review, the ambulance provider will receive one letter requesting documentation for every flagged claim, usually for the same service, to be reviewed individually. These reviews are typically triggered when the Medicare contractor determines that a provider ranks higher in ALS or emergency procedures as compared to their geographical peers. This is often apples to oranges, as the country fire/EMS service will naturally have a different patient profile than a private ambulance service specializing in dialysis or nursing home transports.

A post-payment review examines the provider’s entire universe, using a set of randomly selected trips for statistical analysis. (RAT-STATS, the statistical tool used for these reviews, is available as a free download for providers to perform in-house compliance audits). The provider then is required to submit all of the medical records for those trips to the MAC.

If the MAC’s analysis determines a high rate of error, that rate is extrapolated to all the claims across that provider’s universe. For example, if they determine a 40 percent error rate on 90 randomly selected trips over 24 months, then Medicare has the justification to apply that error percentage to every claim submitted in that same two-year period.

The provider will then receive a letter that specifies an amount that must be repaid. If Medicare doesn’t receive payment within the allotted time, the money – plus interest – will be withheld from future checks.

It’s important to have an active compliance plan in place, as well as a compliance manager to conduct internal quality assurance audits. Part of that compliance plan should include training for both medics and billing staff to ensure that they are up to date on the latest regulations. This demonstrates due diligence if you are audited.

Train medics on what information is needed in a patient care report to support all procedures and medications provided so that the billing department can apply the correct codes. That training should not be geared toward getting every claim paid. Details matter, but medics should never add or omit information to justify basis for payment.

Also be sure to provide the required signatures, which will include both billing authorization and medic signatures. It is also important to ensure that the appropriate verbiage is available on the PCR as well. Make sure that medics’ signatures are legible and their credentials provided on each PCR. (PCR software helps with this requirement by providing e-signatures when medics log in.) Non-emergency ambulance transports also require a valid physician certification statement with legible signatures from an appropriate medical clinician (MD, RN, etc.).

Stand by your coding and don’t be afraid to appeal. The Medicare appeals system has four sequential levels. The first two are reviewed by Medicare contractors and handled by written correspondence. The third and fourth are reviewed by independent contractors or an administrative law judge, and providers can request a call or visit to discuss the issue. Further appeals go to federal court.