Compliance Benchmarks

1. Compliance Benchmarks EMSPIRE 2013

2. Compliance Performance Indicators (CPIs) • EMS Insider – April, 2013 • Page, Wolfberg, Wirth (PWW) • National EMS Industry Law Firm • Compliance Benchmarks • Compliance Performance Indicators (CPIs)

3. EMS|MC As your third party billing agency, how do we measure up to these Compliance Benchmarks/Compliance Performance Indicators (CPI)?

4. Service Mix • Service Levels: • BLS, Non-Emergency • BLS, Emergency • ALS, Non-Emergency • ALS, Emergency • ALS2 • Specialty Care Transport

5. Service Mix • Monitoring of Service Mix Percentages • Identify High % of ALS Calls • Identify High % of Repetitive Patients • CMS National Statistics: • 67% ALS • 33% BLS • EMS|MC Statistics*: • 61.4% ALS • 38.6% BLS *CY 2012 Data – as of 05/28/2013

6. Service Mix • Why is it important to review service mix? • Medicare Contractors review this information. • Comparative Billing Reports (CBR) recent mailed to providers that ranked higher than their peers. • EMS Industry standards were not taken into consideration (i.e. EMS/911 services paired with Private Non-Emergency) • OIG Work Plan – Comparative Billing Report for Non-Emergency and Repetitive Patients • Qui Tam/Whistleblower Audits • Several False Claims Act Investigations Nationwide

7. Service Mix • Risk Factors • BLS - Non-Emergency • Medical Necessity • Physician Certification Statements • Repetitive Patients • ALS - Emergency • ALS Assessment – Written Policy • Standard Dispatch Protocols • ALS Interventions

8. Payer Mix • Payer Categories: • Medicare • Medicaid • Commercial Insurers (includes TPL, Facilities) • Private Pay (Self Insured) • High Percentages of Self Pay • May indicate opportunities to capture insurance information or identify proper payment sources

9. Payer Mix • Identify Benchmarks and Trend Analysis • Healthcare Reform • Healthcare Exchanges • Medicaid Eligibility Expansion • Economy • EMS|MC Statistics*: • Medicare 39.3% • Medicaid 10.0% • Insurance 28.9% • Patient 21.6%

10. Miscellaneous Metrics • Credit Balances • Federal False Claims Act • Governmental Payers • 60 days from date identified • Denied Claims • Benchmarking can identify potential problems with documentation, or payer specific issues.

11. Claims Billed for Denial • Percentage of Claims Billed as Non-Covered Services • Medicare expects a submitted claim meets all of the requirements for coverage. • Modifier GY indicates the claim is billed for denial purposes only. • “if non-covered modifiers are used too sparingly, it may indicate that Medicare is being improperly billed for payment.” Doug Wolfberg, PWW

12. Claims Billed for Denial • Recent Federal Fraud Cases • False Claims includes submission of claim for services that did not meet the medical necessity requirements. • Providers must assure the medical necessity requirements are met prior to submitting a claim seeking reimbursement for the service.

13. Patient Signatures • Medicare Patient Signature Requirements • Patient’s Signature • Authorized Representative • Crew and Receiving Facility Signature • Attestation that Patient was unable to sign and reason why • Patient Invoice Cycle • Allows patient to provide valid signature prior to submitting claim • Further collection efforts when patient does not comply

14. Final Caveat • Recognize certain metrics may appear positive but may be masking other problems. • For example, a 45% Collection Rate by Third Party Collection Agency • May indicate Front End Processing may be sending claims to collection agency prematurely • EMS|MC Statistics: • Average 8-12% Collection Rate with Collection Agency and Debt Setoff Programs

15. EMS|MC Metrics • Daily Management Review • Quarterly Compliance Review • Revenue Billed • Revenue Received • Quality Assurance • Claims Inventory • Denials Inventory • Claims Transmission • Customer Service Matrix • Service Mix • Repetitive Patients • Refunds • Claims Billed for Denial • Signature Requirements • Fractional Mileage