My paramedic preceptor told me many years ago, “You’re a paramedic, billing isn’t your job. A patient doesn’t want to be asked their social security number when they’re having a heart attack.” Consequently, I didn’t pay too much attention to the back of my run forms. Sometimes I’d turn them in with the backs blank and not hear much about it. Every now and then, I’d get them kicked back and I’d be told to fill out the back. I’d fill out the back, but not always get the insurance information. Then at work they started a program where you got a dollar for every patient you obtained full billing information on. That was great. I got insurance on everyone and was pulling in an extra $25-$30 a week. That program didn’t last. A new company came in and we were told it was our job to get the information, and we shouldn’t have to be paid to do a job we were already being paid to do. I’d get the insurance information, but not if it wasn’t readily available. If the patient had it on them, fine. If I had to track it down, that was another story. And signatures. I’d get signatures if the person was talking to me and not in any kind of distress, but my compliance wasn’t near 100 percent. Sometimes I’d get the forms kicked back. You need a signature or a reason why they couldn’t sign. My favorite was when this would happen on cardiac arrest patients. Reason signature not obtained: Patient DEAD! Of course it wasn’t just dead people I wasn’t getting the signature on. Some of our patients are shhh! pretty nasty. Not the type of people you want to hand your pen to. My old reliable standby was: Reason signature not obtained: PHGLEM ON FINGERS. But times are changing. I just sat through a two hour long class on documentation that told us how Medicare is refusing to pay many of our bills because the information on the back of the cards is not complete, the information doesn’t match what is on the front, there is no signature, there is no signature from the receiving facility acknowledging receipt of the patient. I was told Phlegm on fingers was not acceptable as a reason signature was not obtained. Your run form isn’t complete, it comes right back to you. I admit I am like a dog. You beat me over the head a few dozen times and I am trained. You let me wander, and I’ll wander. You build an invisible electric fence around me and zap me every time I cross its border, I will soon cease my wandering ways. I admit to taking a certain pride now in turning in a completed run form with all the “t”s crossed and “I”s dotted. Much in the same way when I was a new EMT I enjoyed properly c-spining a patient, securing all the straps and the towel rolls. There is a hospital where we transport patients that really annoys me. When we bring the patient in, we have to stop and get the patient registered first. The triage nurse will not even look at us until the patient’s name pops up on her computer. Sometimes we arrive and there is no registrar there. The nurse will go find the registrar, and then sit and wait for her to register the patient before getting our verbal patient report. (To be fair, if we are bringing in a cardiac arrest or a full trauma patient, they do have procedures for us to go right past GO). I was there the other morning and one of the hospital big wigs was there glad-handing with the staff when we rolled in. No registrar. We sat there while he glad-handed (his back was to us). I saw the triage nurse start to get nervous and then she ducked out and dragged a registrar out of the break room. Another nurse started asking us questions about the patient before the registration was done. I really wished the bigwig had been there at a truly busy time and wished the staff had acted the way they normally do, and it could have been explained to him that per the hospital’s policies (not the nurses) care at his hospital doesn’t start until the patient is registered and has confirmed billing and signed the proper forms. I was at the same hospital later that day when I heard a firefighter/paramedic say to a family member, “We’re fire-medics we don’t care about billing. Your mother shouldn’t have to worry about giving out her social security number when she’s sick. That’s for the commercial ambulances.” That comment really ticked me off. Arrogant prick, I thought. I have always been a medic who works up his patients fairly thoroughly. If you are old and not feeling well, you get an ALS workup. IV, monitor, 02 if you need it. I do it to be thorough, and also when I was a newer medic, it helped me hone my IV skills. I could justify it both as being thorough as well as enabling the company to get the ALS rate rather than the BLS rate. Back when we used to draw bloods, I’d draw the bloods. I remember at the time another ambulance service told its medics not to draw bloods because the cost to the service was too great (IV plus bloods was the same billing rate as IV). I liked that our service never once questioned our care. Sometimes you could say the IV and the bloods were done more as a convenience to the hospital than absolutely medically necessary. Handing over the bloods and saying you had gotten an IV always drew a smile and warm thanks from the ER nurses. Then the hospitals stopped taking our bloods. Some people felt the reason was the hospital could then charge big bucks for the blood draw. $100 or more bucks for a blood draw on an itemized bill. Everyone looking for revenue. At the documentation class we learned that while Medicare is making it much harder for ambulance companies to get paid, they have changed things so that an ambulance company can get a paramedic rate simply for an evaluation as opposed to doing actual paramedic skills. For instance having a paramedic evaluate a patient produces a bill the same amount as when a paramedic does an IV and pushes 2 ALS drugs, including drugs that can be very expensive. Only if the medic pushes a 3rd drug does the bill go up. So whereas in the past, my putting in an IV lock brought in increased revenue to an ambulance company, now it costs them money. I don’t pretend to understand all the intricacies of billing nor do I have an idea of a fairer way to bill. I’m just pointing out that there are many calls that cost the ambulance company way more in supplies and medicine than they can bring in (not to mention the calls they simply don’t get paid for) and there are calls that are very profitable. I am sure hospitals face the same thing. At the end of the year, they are either in the red or in the black. Too many years in the red and they go out of business. This happened to the first ambulance company I worked for( a small private company in Massachusetts). We started having supply issues, and then we noticed we were being sent out on the road in unsafe ambulances, and then we had to race to the bank on payday to get our checks cashed before they bounced (which sometimes happened to those who waited until Monday to cash theirs), and then one day they told us they were boarding the place up. Instead of complaining about unsafe ambulances, we were complaining about the line at the unemployment office. There is always talk these days of paramedic shortages. But there are way more paramedics now than there were when I started when some people who went to medic school couldn’t even get precepted because there were so few paramedic slots to fill (Medic salaries were much higher than EMTs back then). Changes in billing have made it more profitable to have more paramedics. Some services strive for a paramedic on each ambulance. I don’t mean to point fingers here at anyone. I just think that we are all naïve if we say money isn’t a factor. We may not have gotten into this business to make money, but we all need to live. If we think what we do is important, we need to get paid for it. If we find ourselves with crappy equipment and low wages, it might be because we are not doing a good job of recovering what we are worth. Some hospitals close because the cost of the care they provide is greater than the money they bring in. If a fire service doesn’t want to bill the insurance companies or federal government for the services they provide, well, the people in their town are just going to have to pay higher taxes to support that fire service. Someone has to pay for those saline locks, that LifePack 12, and that dose of Zofran. A few years back many volunteer services refused to charge because they were VOLUNTEER, but with time, just about all of them now bill. They faced reality. They may not sic aggressive bill collectors on their patients, but they certainly do bill everyone with insurance and rightly so. What does this all mean for me? I will try to fill out the backs of my run forms and get the needed signatures. I am not going to withhold treatment before I get insurance information. No one has ever suggested that. But in response to my first preceptor, I have to say collecting billing information is part of my job. Nothing comes for free. We – commercial services, volunteer services, fire services, hospitals — are all professionals – and we need the resources to do our jobs. And I still love my job.
