Hospital to Hospital transports from an RCM perspective

December 13, 2021

Revenue Cycle Management(RCM) in the ambulance industry has a lot of moving parts to monitor to ensure the bottom line is met.  Lower DSO, maintain a steady cash flow, keep a close eye on outstanding AR, and create a healthy working relationship with their clients.

The following scenario outlines a potential cash flow issue if it is not managed properly.  This scenario pertains to Medicare patients who are transported from one hospital to another hospital.

When Mary received a bill for her recent ambulance transport for $1,500, she almost had to call 911 for another transport!  What Mary didn’t realize was that she should not have requested to be transported to another hospital for personal preference.

Let me explain “personal preference.”

Mary was scheduled to have a procedure performed that was available at the hospital she had been admitted.  After Mary had seen her own PCP and realized he was not able to perform the procedure in that hospital, Mary requested to be transferred to the hospital where her PCP could perform the procedure.  Due to the fact that she was already in a facility that could provide the service, Medicare would not pay for the ambulance transport to another facility.  Mary now has a hefty ambulance bill she will need to pay for, out of her own pocket.

When being transported between two hospitals for medical care, the key factors to keep in mind are, can the current hospital complete the care or procedure that is needed, and is there medical necessity.  What is Medical Necessity you ask; Medicare defines this as “Services or supplies that are needed for the diagnosis or treatment of your medical condition and meet accepted standards of medical practice.” If a patient meets the requirement for going to another hospital because the originating hospital is not able to perform the needed care, the patient must not be able to walk or be transported safely by any other means.  If the patient is able to transport by other means, the medical necessity piece of this equation is not met and Medicare will again deny leaving the patient responsible for the ambulance ride.  A completed Physician Certification Statement (PCS), by the treating physician at the sending hospital would need to be obtained indicating the patient could not safely travel by any other means, and the reason why the patient is being transported to another facility.

The ambulance crews are also responsible for obtaining the needed information to include on the Patient Care Report (PCR).  They will discuss the reason for the transport with the sending facility, or the patient, regarding why the patient is going to the next hospital.  They will assess the patient and notate whether or not the patient could have safely traveled by any other means. The documentation from the PCR and the PCS holds crucial information that is needed in order to properly bill the claim to Medicare for payment.

At the end of the day, the RCM agency that is billing thousands of claims daily is expecting to bill clean claims that will result in quick turnaround from Medicare, among other payers.  This not only helps a steady cash flow, but it helps keep a positive relationship between the client and the RCM organization.  It is important for the RCM organization to fully understand billing guidelines when it comes to Medicare, state Medicaid programs, and other commercial and contracted payers.  When this type of detail falls to the wayside, that perfect relationship that was built with those clients will be tarnished and it will become more difficult to prove your organizations worth.