What if every time you had a patient in v-fib, you were allowed to shock him only once? What would your success rate be? Everyone in EMS knows that defibrillation often works only on the second, or even the third, shock. The same principle holds true when it comes to getting reimbursed for medical transportation. It often takes one, even two, appeals before claims are paid. In fact, as many as 50 percent of denied claims are eventually paid when the provider appeals the Explanation of Benefits (EOB).

“Insurance companies deny thousands of claims a year with what appears to be substantial evidence to support such non-payment,” explained Tammy Tipton, president of Appeal Solutions, a manufacturer of software to help process EOB appeals. “They do this knowing that most denials are accepted without question or action. They know many medical providers do not have the time, legal expertise and insurance industry experience to investigate the basis, or lack thereof, of claim denials.”

EMS services need to appeal every denial, Tipton went on to say. “Establish yourself as very aggressive on appeals. Then the carrier begins to recognize you as someone who will appeal, and if there’s ever any gray area on your claims, they will pay because they know if they don’t, they will hear from you.”

Medical Necessity Denials

In the federal and commercial areas, many EMS claims are denied for lack of “Medical necessity.” This denial is very common in air medical services, which are not only very expensive but also can be considered medically unnecessary if similar ground transportation is available.

Medical necessity denials do not have to be accepted. The first step to appealing them is to demand proof from the insurance carrier to substantiate the denial. Call the carrier and ask specifically what led the claims processor to believe that the transport was medically unnecessary. Ask what additional documentation he or she would need to overturn the denial.

Many times, the claim will turn on documentation of medical necessity, but EMS providers and physicians must be schooled in writing down the specific information that the claims processor wants to see. In no case is medical necessity documentation more important than in critical care transport. “If a Letter of Medical Necessity is needed, the best way to get a letter containing the appropriate information is to call the doctor’s office and speak directly with the doctor and explain what you need and why you need it,” said Linda Kilgore, office manager for Med Flight Air Ambulance in Albuquerque. When Kilgore makes these calls, she asks that the physician’s letter includes:

- A detailed description of the patient’s condition

- The reason that the patient could not receive appropriate treatment at the referring hospital

- A detailed description of the therapies that were available only at the receiving hospital

- The reasons that the patient could not be treated at a medical facility in close proximity to the referring hospital

- The reason that the patient could not be transferred using other means of transportation

In addition to telephoning the physician or requiring similar documentation of medical necessity from your paramedics, shift supervisor or medical director, Tipton suggests calling the patient directly to inquire about coverage. Ask the patient to scan his insurance policy and to read you the section on medical transportation. If the denial seems out of line with the policy, obtain a copy of that portion of the policy to include in your appeal. Suggest that the patient also files an appeal, Tipton said, as a second appeal will support your case.

Precertification Denials

As hard as it is to believe, Tipton said that she still sees a lot of denials related to lack of precertification for medical transportation even though many states prohibit insurers from requiring precertification on emergency services. “You should always appeal this type of denial,” Tipton advised. “It’s unconscionable that they would deny for that reason.”

Regarding non-emergency transports, Kilgore said: “Medicare and Medicaid will not pre-approve air ambulance transportation; however, most private insurance companies now require it. At the time of the initial call, if time allows, prior approval can often be obtained from these insurance companies with a couple of phone calls. The process requires more work, but can benefit you by ensuring faster payment by submitting the claim with the approval number.”

Slow Payment and Low Payment

Most states have laws and regulations that protect EMS providers from slow payment and low payment by commercial insurers, and one-half require insurance carriers to pay interest on late payments under certain circumstances, Tipton said. But the only way to collect this money is to demand it in writing. “Put insurers on notice that staff reductions, computer downtime, and bureaucratic inefficiency can no longer be an excuse for long processing periods,” she said, adding that typical timely payment statutes require payment in 45 days or less.

EMS services also can appeal low payments that the carrier says are based on “usual and customary charges” for your region, if the fees are not associated with a contractual agreement. “Medical providers are under no obligation to agree to price reductions not associated with the contractual agreement,” said Tipton. “Therefore, medical providers need to educate their staffs on what charges are subject to write-offs and which ones should be pursued for full payment.” For example, if the usual and customary reduction reduces your payment to 50 percent of the full charge, but the patient’s benefits say that medical transportation is to be paid at 80 percent, then an appeal can be submitted on the basis that the carrier is not honoring the benefits.

With all denial appeals, you have to be persistent. “Follow up is absolutely crucial,” said Tipton. “Carriers lose appeals letters left and right because they are processing such a huge volume of accounts. Follow-up so that your claims are the ones that get attention. Call them as often as you can. Re-fax your appeal to the person you talk with on the phone.”

“Remember, tenacity may be your biggest asset when appealing claim denials,” Tipton said. “Do not give up until you are satisfied with the answer you receive.”