Managing ambulance medical claims processing can be an extremely complex task—these best practices will help.

An insurance claim is a collection of data: We transported this patient (patient demographics) on this day (DOS encounter data). They had this issue (coding), we did this for them (coding), and they have this insurance (insurance data).

Get those five pieces of data right, and you will get paid; get any of them wrong or miss any information and getting paid is nothing short of a challenge.

To help prevent EMS medical claims processing challenges like getting wrong information or not securing what you need—here are six important best practices to follow.

EMS Claims Processing Best Practice #1: Understand the differences between appeals and corrected claims.

When ambulance claims are denied, billers may either appeal the claim or submit a corrected claim to seek reimbursement for the services rendered. In order to ensure proper reimbursement, every EMS biller managing denials should understand the difference between the two, and they must follow state and payer guidelines for submitting both.

When appealing a claim, you are advising the insurance payer that the codes billed are correct, and you are providing further documentation showing that the codes are reimbursable as billed.

For an appealed claim, you must supply documentation to support your appeal. Make sure to include the patient care record/narrative, any relevant amendments, the invoice, your official letter of appeal and a copy of the original claim. There are state-specific guidelines that can be used as well as payer-specific appeal processes.

When filing a corrected claim, you are advising the insurance payer that you would like to amend items like the CPT, ICD-10 and/or HCPCS codes originally billed. Knowing the difference between these codes is important so that the claim is re-processed correctly and promptly.

For a corrected claim, the appropriate changes should be made to the CPT, ICD-10 or HCPCS codes, and the bill type should be changed to reflect a corrected claim. If the bill type is not changed, it could be denied as a duplicate bill. The corrected claim should then be submitted electronically to ensure the quickest reprocessing.

EMS Claims Processing Best Practice #2 - Review rejection reports daily.

Review all electronic claim rejection reports daily in order to determine where in the pathway the claim was rejected.

Reviewing reports will allow EMS billers to determine if the cause for the rejection was in-house, with a clearinghouse, or with a direct payer.

If errors were introduced by the EMS billing staff, billing managers can take steps to improve processes and reduce in-house errors. If errors appear elsewhere along the pathway, EMS billing managers should determine why the claims were rejected then call the clearinghouse or payer to investigate further.

Some of the most common rejections are for invalid insurance ID numbers, missing DOB, invalid diagnosis code, demographic errors, and misspelled names. Many of these can be avoided if you have a quality EMS billing software that allows you to implement safeguards to prevent common billing errors.

EMS Claims Processing Best Practice #3 - Enforce processes that will reduce the chances of claim rejections.

You can reduce the chances of claim rejections by implementing processes that reduce the potential of them happening in the first place. To do this, billers must understand the electronic pathway of claim submissions for each payer.

Knowing the pathway of claims can also give billers a better idea of how long claims will take to reach payers.

Electronic claims are sent to an EDI company and, in some cases, on to several trading partners before the claim reaches the payer. The longer the path the claim takes, the more opportunity for errors.

Billing managers can begin to chart the path by following a claim from the ambulance provider to the provider’s EDI company and then determine if the claim goes directly to the payer or to an additional trading partner. In order to reduce the number of steps in these pathways, seek out EDI companies that have direct contracting agreements with most, if not all, of your EMS agencies primary payers.

EMS Claims Processing Best Practice #4 - Scrub claims for errors before submission.

We use the phrase “scrubbing out claims” to describe our process of reviewing claims for errors before submitting them to payers.

“Scrubbing” includes spot checking all major payers for compliance issues, diagnosis issues, and other possible coding errors.

If the scrub process is clearly defined, it can greatly improve the chances of having a clean claim which reduces days in accounts receivable and increases your reimbursement.

Another aspect of scrubbing is making sure you’re using the correct codes. Leveraging ambulance claims management technology tools—not sticky notes all over your computer—will automate your processes and ensure your forms are updated with the ever-changing ambulance coding guidelines.  

EMS Claims Processing Best Practice #5 - Consistently monitor the status of claims.

An EMS biller may do a great job of getting claims out of the door but may fail to monitor the status of claims once submitted.

If the EMS provider doesn’t have a documented process as to how and when to follow-up on pending bills, collection odds will decrease and labor required to clean up accounts receivable will increase.

The bottom line is—always monitor the status of claims until they’re closed.

EMS Claims Processing Best Practice #6 - Implement an integrated EMS workflow.

Revenue cycle management works best when all systems and departments are thoroughly integrated. However, many EMS billing departments, dispatch offices, and patient care departments remain in their own silos working independently.

A five-star claims management solution can provide reports and analysis capabilities to help you uncover hidden causes of issues and engage departments all along the revenue cycle for a cleaner, more transparent workflow.

We have one of the best claims and revenue management systems in the industry. Our EMS workflow ties departments (dispatch, ePCR, and billing), reporting, and analysis together seamlessly. Because our software is cloud-based and capable of fully integrating all vital departments, it avoids the most common rejections for electronic claims and it’s always up-to-date on the constantly changing requirements of your payer mix, state requirements, and changing reimbursement methods.

Discover all the advantages and benefits of our EMS workflow software. You’ll see why we call our workflow The AIM Advantage.

Are you ready to talk about your EMS medical claims processing challenges and how we can help, or are you interested in a free demo? Start here.

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