1 ALAMEDA FIRE DEPARTMENT
Subject: EMS Billing Policy Policy Number
GOB 1-62
Approved By: Chief Nicholas Luby Page: 1of 6
Refer To: Deputy Fire Chief of
Support Services
Effective Date:
November 17, 2011
Policy Review Date: April 2026 Revised Date:
April 18, 2024
Operations Volume
PURPOSE: The purpose of the Emergency Medical S ervices Billing Policy is to provide information and direction on billing and collection for the Alameda Fire Department's and ambulance transport services.
RESPONSIBILITY: It is the responsibility of the Alameda Fire Department to seek reimbursement for emergency medical services and ambulance transportation expenses from patients including those covered by third- party insurance agencies. All personnel are responsible to understand and comply with this policy.
POLICY: It is the policy of the Alameda Fire D epartment that emergency medical services and ambulance transportation services will be billed for as applicable within this policy.
The Alameda Fire Department is sensitiv e to the needs of patients and their ability to pay for ambulance transport and EMS services. Our billing contractor is conscientious about billing and collecting fees for these services. Therefore, it is the policy of AFD that only after multiple and thorough attempts have been made to collect ambulance transport and EMS fees will a collection agency be considered.
DEFINITIONS
A. AFD – Alameda Fire Department
B. Advanced Life Support ( ALS) or Basic Life Support ( BLS) Assessment - Assessments are comprised of any skill or tool available to Alameda Fire Department EMS personnel which is used to evaluate a patient's mental status, vital signs or other body functions for the purposes of determining if ALS and/or BLS interventions and/or transport are necessary in the best interest of the patient.
C. ALS Intervention - The act or a method of interfering with patient outcome or course by performing Advanced Life Support (ALS) skills such as inserting an IV, administering medications, performing advanced airway maneuvers, or other treatment that would normally be considered in a Paramedic's scope of practice in Alameda County. Skills that are utilized by a Paramedic to determine if ALS interventions and/or treatment are necessary, such as 12 -Lead acquisition or glucose testing, will be considered part of a patient assessment.
2 D. AMA- Against Medical Advice , when a patient is offered an evaluation, medical care and/or transportation to a medical facility and refuses the services offered.
E. BLS Intervention - The act or a method of interfering with patient outcome or course by performing Basic Life Support (BLS) skills such as administering oxygen, performing chest compressions or ventilations with a bag valve mask, wound care, splinting or other treatment that would normally be considered in an Emergency Medical Technician's scope of practice in Alameda County.
F. DOD – determination of death
G. EHR – electronic health report (patient care report) H. EMS – Emergency Medical Services
I. ESO Solutions – software used by AFD EMS personnel to complete patient care reports J. Face Sheet - The hospital emergency room/admitting registration form that includes the patient's demographic and insurance information.
K. HIPAA- Health Insurance Portability and Accountability Act is a federal law enacted by Cong ress to protect and secure health records. Health providers, health insurance plans, and clearinghouses are required to meet HIPAA standards.
L. PCR - Patient Care Report. Required by Alameda County protocol to be completed for every patient, describing the c are rendered and provided to the staff at the receiving hospital. Exceptions are for multi-casualty incidents and refusal of service.
M. Skip Tracing - Process by which additional information is obtained by the billing contractor, e.g., SSN, and/or tracing a patient’s residence chronologically to obtain a valid patient mailing address.
N. TNT – Treatment/Non-Transport. TNT applies to patients who are assessed and treated on-scene by the ambulance crew, but who refuse transportation to the hospital.
Alameda County EMS policy must be strictly adhered to when considering refusal of transport. A TNT trip that include ALS interventions is billable.
O. Refusal of Service - Applies to those persons who are refusing all EMS services including an assessment and transportatio n. Patients who refuse service cannot be billed.
P. Quality Assurance/Quality Improvement – The process by which the Alameda Fire Department reviews and improves the delivery of emergency medical services.
BILLING PROCEDURES:
The AFD seeks reimbursement for EMS and ambulance transportation services, including treatment when ambulance transport is not provided.
The Fire Department shall bill for applicable services of an EMS response whether or not the patient and/or the primary on scene medical provider deems ambulance transport is necessary. 3 911 System User Fee Calculation:
911 System user fees are determined by the Alameda County Emergency Medical Services Agency (ALCO EMS) and approved by the Alameda County Board of Supervisors. Changes to user fees a re determined by ALCO EMS utilizing the established parameters contained in the Alameda County Contracted 911Ambulance Transport Provider Agreement. The calculations utilized to determine the maximum allowed fees are covered in the “Contracted Revenue” se ction of the agreement between the County and the contracted private ambulance provider. Appendix B contains the “Contracted Revenue” section of the County agreement. The City of Alameda can increase our user fees to remain equivalent to the County’s Con tracted Private Provider rates per the City’s agreement with ALCO EMS (Section 10.2 and Exhibit G). Annually in July, the ALCO EMS provides all 911 ambulance providers (private and public) in the County with an updated fee schedule in accordance with Sect ion 10.2 of the City’s agreement with the County, and Exhibit G can be amended if approved by the City Council.
AFD EMS and Ambulance Transport Fees:
First Responder Fee:
The first responder fee is for paramedic level services in responding to emergency medical service calls.
Treatment/Non-Transport (TNT) Fee:
The treatment/non-transport fee shall be limited to patients who receive an ALS medical intervention, such as intravenous medication administration, and subsequently refuse transport.
Transport Fee:
When a patient is transported to the hospital in an AFD ambulance.
A. Billable Incidents – All calls for EMS service which result in the following situations:
1. First Responder fee is charged for responses to emergency medical service calls.
2. Treatment/Non-Transport fee is charged when a patient receives ALS interventions performed by AFD EMS personnel. (See exceptions listed in Section B.)
3. Transport fee is charged when a patient is transported by an AFD ambulance.
B. Non-Billable Incidents – It is the policy of the AFD to provide EMS services at no cost to the patient when the following conditions are met:
• patient assist without need for medical services (e.g. assistance getting back into bed); and
• patient or designee, did not call for service (e.g. friend or neighbor called) and patient refuses medical care.
• DOD – at no time will the family of the deceased patient be responsible for an u npaid remaining balance after the insurance carrier has paid or denied a claim. • Law enforcement requested treatment or transport for victims of violent crime.
4 Billing accounts 180 days or older may be sent to a collection agency, unless the account is active.
Refer to the Emergency Medical Services and Ambulance Transport Billing Protocols on page 5 for additional information.
BILLING DOCUMENTATION
The following documentation is needed to submit a claim: Patient name, patient date of birth, patient sex, patient social security number (or last four digits), Medicare unique id number or insurance policy number, patient condition, patient signature, or signature of patient’s representative or hospital representative, pick up location, destination, chief complaint, date of service, time of events, level of service, vital signs, narrative, supplies used, medication s – dosages and times given, and loaded fractional mileage.
Ambulance Crew – for all transports, the ambulance crew shall make every attempt to obtain the patient’s signature on the PCR. If the patient is incapable of signing, the crews shall document th e reason and obtain a signature from the patient’s representative. If a patient representative signature is not obtain ed, the crew shall document a legitimate reason as to why the patient and/or patient representative was unable to sign and shall obtain t he signature of the hospital representative, acknowledging the patient’s name and time of transfer of care, and obtain a copy of the hospital face sheet for all patients transported to a hospital. Electronic copies of the face sheets shall be attached to the patient care report.
Please note that anything documented that is related to the patient’s mental status or points to a specific cause why the patient cannot sign as the reason that you were unable to obtain a signature must be included in the assessment/narrative of the PCR as well as in the “unable to sign” section of the PCR. Some key things that can be documented for failure to obtain a signature are:
Patient was unconscious and could not hold the stylus/pen Patient had a decreased level of consciousness and could not sign Patient had suffered a cerebrovascular accident (stroke) and could not hold the pen Patient was in shock and could not follow instructions to sign Patient was in cardiac or respiratory arrest
Patient had a traumatic brain injury and was not compliant with requests Patient was combative and could not follow directions Patient was hypoxic and/or hypotensive and could not follow directions Family member (or nurse, etc.) refused to sign
Situation unsafe for AFD personnel to obtain si gnature (details must be documented within the PCR narrative)
CRITERIA FOR REDUCTION OR WAIVER OF EMS OR AMBULANCE TRANSPORT FEE
The Alameda Fire Department is committed to maintaining consistency in assisting uninsured and indigent patients, or patients experiencing financial hardship, who request a reduction or waiver of certain EMS and ambulance transport charges and/or co-payment amounts.
A. Upon request, EMS or ambulance transport fees will be reduced or waived based on the following criteria:
1. Patients whose total annual household income is less than three hundred and fifty percent (350%) of the current Department of Health and Human Services Poverty Guidelines.
5 2. The patient was a victim of violent crime.
B. Patients with health insurance who qualify for a reduction or waiver of the EMS or ambulance transport fee will only be granted a reduction or waiver of the patient balance (out -of-pocket expense).
C. Reduction or Waiver of Fee Procedure:
1. Requests for reduction or waiver of EMS or ambulance transpor t fees will be referred to AFD personnel at [email protected].
2. AFD personnel shall log and track all requests for reduction or waiver of fees.
3. The AFD Financial Hardship Application and attached Appendix A (Department of Health and Human Services Poverty Guidelines) will be sent to the patient. The patient shall complete the Hardship Application and Financial Statement and return to the [email protected] email address within ninety (90) days of receipt of the application packet.
4. All fee reductions or waivers will be approved by the Fire Chief or designee.
5. AFD personnel shall attempt to notify patient within forty-five (45) days of the approval or denial of a reduction or waiver of fees.
6. AFD personnel shall forward the approval or denial of reduction or waiver request to the billing contractor including the account number, patient name, dollar amount and reason for reduction or waiver or denial of hardship claim.
EMS AND AMBULANCE TRANSPORT BILLING PROTOCOLS
1. In order to ensure accurate billing, Alameda Fire Department personnel will make every attempt to provide accurate patient and insurance information in each electronic patient care report.
2. The billing contractor uses all available methods to identify missing or incomplete patient information. These methods include, but may not be limited to skip tracing to find social security numbers if the patient’s date of birth and address are unavailable; and conduct insurance eligibility checks if patient’s social security number is unavailable in order to bill major payers, i.e. Medicare, Medi -Cal, Kaiser, Blue Cross/Blue Shield, United Healthcare, Aetna, Cigna, etc.
3. The billing contractor bills third-party payers and/or patients based on the information provided by the Alameda Fire Department, and any other credible third-party source.
4. When a patient’s returned bill provides current contact information, the billing contractor updates the patient account information and resends billing information accordingly. 6 5. If a patient, or patient’s representative, has not responded to three (3) invoices with the patient’s most current and accurate information, a nd two phone calls when that contact information is available, the bill is con sidered for a referral to a collection agency, with the exception of accounts being considered for hardship.
6. Monthly, the billing contractor will provide Alameda Fire Department personnel with a list of accounts for referral to a collection agency. The l ist contains patients whose contact or billing information could not be obtained by the billing contractor, and patients who have not responded to at least three (3) invoices.
7. Within ten (10) business days of receipt, Alameda Fire Department personnel wil l provide the billing contractor with any modifications to the collection list and then final list may be referred to the collection agency. The billing contractor will close and zero balance accounts after the accounts are forwarded to the collection age ncy. The billing contractor will reach out to the collection agency if any payment is received by the billing contractor after the account has been sent to the collection agency.
8. At the direction of the Alameda Fire Department, a collection account may a t any time be recalled from the collection agency and referred back to the billing contractor for billing service.
9. In the instance of pronouncement of death, with the use of Advanced Life Support interventions, the billing contractor will contact patient’ s family for insurance information if crew is unable to obtain on scene. Billing contractor will not bill for co -pays for pronouncement of death patients. At no time will the family of the deceased patient be responsible for any unpaid balance remaining after the insurance carrier has paid or denied a claim. In these instances, the remaining balance will be waived and the account closed.
1 Alameda Fire Department
EMS Billing Policy
Appendix A
Financial Hardship Application
Please complete statement, sign, date and return within ninety (90) days of receipt to the Alameda Fire Department, 1300 Park Street, Alameda, CA 94501. Completed statement may also be sent via email to [email protected].
All information relating to financial hardship requests will be kept confidential.
Patient Name: __________________________________________________________________________ Address: __________________________________________________________________________ Phone #: _________________________ Email: ____________________________________ Date of Service: ______/______/________ Account Balance: $_______________ Incident scene address or location: ___________________________________________________________ Date of Service: ______/______/________ Account Balance: $_______________ Incident scene address or location: ___________________________________________________________ Date of Service: ______/______/________ Account Balance: $_______________ Incident scene address or location: ___________________________________________________________ Date of Service: ______/______/________ Account Balance: $_______________ Incident scene address or location: ___________________________________________________________ Attach copy(ies) of billing statement(s).
NUMBER OF FAMILY MEMBERS LIVING IN HOUSEHOLD: ___________
Family Member Name: _________________________ Relationship: _______________ Age: _____
Family Member Name: _________________________ Relationship: _______________ Age: _____
Family Member Name: _________________________ Relationship: _______________ Age: _____
Family Member Name: _________________________ Relationship: _______________ Age: _____
Family Member Name: _________________________ Relationship: _______________ Age: _____ If additional family members, please attach a separate sheet and include name, relationship and age.
2 Alameda Fire Department
Application and Financial Statement for Financial Hardship Consideration
MONTHLY GROSS HOUSEHOLD INCOME & SOURCE
Patient Spouse or Parents Dependents
Monthly Salary (Gross) $____________ $____________ $____________ Public Assistance Benefits $____________ $____________ $____________ Unemployment Benefits $____________ $____________ $____________ Social Security Benefits $____________ $____________ $____________ Workman’s Compensation $____________ $____________ $____________ Child Support $____________ $____________ $____________ Other (Pension alimony, etc.) $____________ $____________ $____________
Subtotal: $____________ $____________ $____________
Total Monthly Gross Household Income $____________
Please provide applicable documentation of proof of total monthly household income:
? Not applicable ? Pay check stubs for the past 90 days for all employed adult family members in the household
? Not applicable ? Unemployment check stubs for all household members for the past 90 days ? Not applicable ? Proof of all other total household income received in the past 90 days ? Not applicable ? Application forms from Medicaid or other State-funded medical assistance program ? Not applicable ? General assistance income for all household members for the past 90 days
In addition to the above documentation, the patient must submit:
? Most recent signed income tax return, or
? Letter 4506-T from the Internal Revenue Service (IRS) stating they did not file taxes for the year. The current version of this form is not available until after April 15 of each year. The phone number for the IRS to obtain this letter is (800) 829-1040.
Person completing this application (if different than the patient):
Name: _______________________________ Relationship: _______________________________
Phone Number: ________________________
Failure to complete the application or include required financial documentation will result in the denial of your request.
I hereby certify, under penalty of perjury, that the above statements are true and correct to the best of my knowledge.
______________________________________ ____________________________ Signature Date
_____________________________________
Printed Name
3 Alameda Fire Department
Application and Financial Statement for Financial Hardship Consideration
For Office Use Only:
Date Received: ______________________________ Patient Name ________________________
Status Approved Denied
Amount Reduced or Waived: $_________________ Remaining Balance Due: $_______________
Processed by: _______________________________ Signature: ____________________________
Approved by: _______________________________ Signature: ____________________________
Title: _______________________________
Upon completion, the Alameda Fire Department to send a copy of the hardship waiver, reduction or denial to the patient and the billing contractor.
Date Sent: _______________________________ Sent by: ____________________
The Department of Health and Human Services Poverty Guidelines (48 Contiguous States and D.C.):
https://aspe.hhs.gov/topics/poverty-economic-mobility/poverty-guidelines
If the patient’s total monthly gross household income falls within 200% or less of the established HHS Poverty Guidelines for household income, the patient’s account balance will be waived. If the patient’s total monthly gross household income falls with 201% -299% of the established household income, the patient’s account balance will be reduced by 75%. If the patient’s total monthly gross household income falls within 300 - 399% of the established household income, the patient’s account balance will be reduced by 50%. If the patient’s total monthly gross household income falls within 400% or less of the established household income, the patient’s account balance will be reduced by 25%.
Hardship Application_Financial Statement_revised_04.18.24 1 Alameda Fire Department
EMS Billing Policy
Appendix B
Emergency Medical Services Ambulance Transport Services Agreement County of Alameda and the City of Alameda
Section 10 - Contracted Revenue
10.2 User Fees:
a. The County shall establish user fees by a pproval of a majority vote of the Board of Supervisors. C ity is prohibited from charg ing in excess of the approved User Fees as set forth in Exhibit G – City’s User Fees – 911 System.
b. The rates in effect at the time of this Agreement shall be frozen until the County’s Contracted Private Provider rates exceed the rates described in E xhibit G – City’s User Fees . At that time, City’s User F ees will remain equivalent to the County’s Contracted Private Provider rates.
c. In the event that changes occur that r esult in at least a ten percent (10%) in costs for providing services pursuant to this agreement, or at least a ten percent (10%) decrease in total collected revenue compared to the preceding twelve (12) month period, City may request increases or decreases in User Fees. Once the data supporting the request has been verified, the EMS Director shall submit the request and justification for an increase in User Fees to the Board of Supervisors for approval.