Collecting Patient Billing Data

As explained in Section 4.4 of this report ("EMS Billings and Collections"), EMS personnel collect medical and billing data from patients at the scene of a medical incident. Such detailed billing data is critical for the Fire Department"s billing contractor, Allied Information & Services Corp. (AIS), to be able to send the patient a bill and consequently for the City to collect revenue for providing the EMS service.

As part of two separate audit tests (explained below), we reviewed 167 Patient Care Reports (PCRs) and documented their completeness. We believe the Fire Department may be able to enhance EMS revenue collections by: (1) directing AIS to provide training on the collection of patient billing data (2) increasing efforts by AIS and Fire Department personnel to collect billing data soon after EMS service is provided, and (3) negotiating agreements with the hospitals that receive EMS patients regarding the collection of patient billing data.

Audit Testing

We conducted two separate audit tests based on samples of PCRs: (1) to test the timeliness of billings and (2) to test accounts classified as "Incomplete Address" and "Bad Address" to review whether these accounts were appropriately classified as such and to test the extent of research and collection efforts by AIS on these accounts. As part of these tests, we reviewed the completeness of the 167 PCRs sampled in both of these tests and have aggregated the results below.

As a test of the timeliness of billings, we sampled 125 EMS calls from August 2000 through January 2001. Because we were primarily testing for the timeliness of billings, we attempted to select accounts for which a bill would be generated. As a result, this sample may disproportionately reflect PCRs that are more complete than the population of PCRs as a whole. As part of this testing, we reviewed the completeness of the PCRs and billing data for the calls selected. We found the following:

· Of the 125 calls selected, a PCR was completed for 107 (86%). PCRs were appropriately not completed for the remaining 18 calls for the following reasons:

· In the test of "Incomplete Address" and "Bad Address" accounts, we sampled 60 accounts from November 2000 and June 2001. In the case of the "Incomplete Address" accounts, we reviewed the PCR to determine whether the PCR was sufficiently incomplete to warrant designation as an "Incomplete Address" account. With regard to both the "Incomplete Address" and "Bad Address" accounts, we reviewed AIS" billing records to test whether its written procedure had been followed with regard to research of these accounts (see Section 4.4, "EMS Billings and Collections").

The results of these two samples are displayed in tables 4.3.1 and 4.3.2, below.

Table 4.3.1
Audit Test Results for 107
Emergency Medical Calls For Service

In both samples, the patient name and date of birth were the data elements most frequently collected. These were followed by house number and street data. However, even if a PCR includes substantially complete address information such information is not necessarily correct. AIS identifies a number of EMS bills each year that are returned as undeliverable due to bad address information on the PCR. In FY 2000-2001, there were 6,389 such accounts representing $3,057,150 of EMS service. While we acknowledge that EMS personnel are often attempting to collect such data under adverse conditions, we also believe that the significant number of bad address and incomplete address accounts appears to indicate a need for a greater emphasis on the collection of accurate patient billing data.

Table 4.3.2
Audit Test Results for 60
"Incomplete" and "Bad" Address PCRs

Several Fire Department officials whom we interviewed during the course of the audit commented that some EMS personnel do not believe that the public should have to pay for EMS services and that this results in a culture in which some employees do not consider collecting billing data to be a critical part of their jobs. As a result, accounts that are currently classified as non-billable because of incomplete or bad address information may, in fact, be billable to a third-party payor or the patient may be able to pay. We recommend that the Fire Department take steps to enhance training and monitoring in this area and make the submission of complete, accurate PCRs a key component of performance evaluation.

Monitoring Completeness and Accuracy of PCRs

The Fire Department should work with AIS to enhance monitoring of "Bad Address" and "Incomplete Address" PCRs. If identifiable patterns of incomplete, inaccurate PCRs emerge, training should be provided to the responsible personnel. AIS reports that it last provided training on completing PCRs several years ago. More such training should take place. (Such training is consistent with AIS" contract with the Fire Department which states one of the services provided as follows: "When requested, provide revenue enhancement training for EMS Division personnel")

Within the Fire Department, Battalion Chiefs or other supervisory personnel should be directed to regularly sample incomplete PCRs and follow-up with personnel regarding the reasons the data is missing and provide coaching to such personnel about the need to collect complete data. If such reviews become viewed as part of performance evaluation, employees may be more likely to ensure that patient billing data is accurately collected. Sanctions against personnel who repeatedly submit incomplete PCRs would aid in making completeness of patient data a key component of performance evaluation.

Post-EMS Call Data Collection

The sooner after an EMS call that account billing data is sought, the more likely it is to be collected. We recommend that the Fire Department direct AIS to increase efforts to collect data on "Incomplete Address" accounts and that the Department attempt to establish agreements with receiving hospitals for the collection of patient billing data.

Research by AIS and Fire Department

The AIS employee on-site at the Fire Department should be directed to closely review PCRs for which address information is incomplete. The PCR should be compared to the CAD data (either by AIS or Fire Department personnel), which records the initial call for EMS service. In our audit testing, we noted one instance where the PCR included a street name but no house number. The CAD data, however, included the house number and could therefore be used to generate a bill. Currently, CAD data is not typically compared to the PCR. We also noted two accounts, which were classified as "Incomplete Address" accounts, that were for EMS service provided to San Francisco Fire Department personnel. In one instance, the PCR stated that the patient was a firefighter. In the other instance, the patient address and incident location were listed as a San Francisco fire station. In neither case was a bill generated for the service because the accounts were considered to have incomplete address information. While we recognize that comparison of PCR data to CAD data is labor intensive, if done selectively only for accounts for which it might appear to be helpful, we believe it may enhance collections. If the Department determines that it does not, it could always cease such comparisons.

Additionally, in our sample of "Incomplete Address" and "Bad Address" accounts, in 35 instances we were unable to determine what, if any, research AIS had conducted on these accounts (see "EMS Billings and Collections" section). The Fire Department"s contract with AIS should identify the specific steps AIS will take with regard to researching incomplete billing data and require AIS to document those steps. Examples of such steps include AIS research of its own database, attempts to establish third-party payor coverage, repeated attempts at contact with the client, etc.

Agreements With Hospitals

EMS personnel transport patients to the following 12 Bay Area medical facilities: (1) Chinese Hospital (2) California Pacific Medical Center-Children"s (3) Davies Medical Center (4) Kaiser Permanente Medical Center (5) California Pacific-Pacific Campus (6) Saint Francis Memorial Hospital (7) St. Luke"s Hospital (8) St. Mary"s Medical Center (9) San Francisco General Hospital (10) University of California at San Francisco Medical Center (11) Veteran"s Administration Hospital (12) Seton Medical Center in Daly City. When a PCR is incomplete with regard to the billing data, AIS researches it and, if unable to collect the necessary data, sends a questionnaire to the hospital. AIS reports, though, that it is often difficult to get hospitals to provide a response. A Fire Department official whom we interviewed stated that he would like to establish agreements with the hospitals stipulating that they will provide patient billing data to the Fire Department when it is requested. We agree with this objective and believe it may help to increase EMS revenues. We recommend that the Fire Department attempt, as soon as possible, to negotiate such agreements. The City Attorney"s Office advises that California Civil Code Section 56.10(c)(3) permits hospitals to provide billing data for the purpose of collecting payment. The hospitals might request that the Department and AIS agree to keep the billing data confidential, which the Department and AIS already do with data they have collected.

Additionally, the local EMS Authority (the Emergency Medical Services section of DPH) currently has agreements with local private hospitals for the exchange of patients between those hospitals and San Francisco General Hospital. The EMS Authority indicated to us that it will attempt to negotiate a requirement that the hospitals provide patient billing data in its agreements, which will be renegotiated in the next year. Even if this occurs, we still recommend that the Fire Department also work directly with the hospitals

Collections Impact

Based on the information available for this study, we are unable to project the additional revenue that would be received by improving the collection of billing information from EMS patients. However, we believe it would be significant. If only one percent of the $6,534,492 in accounts classified as "Bad" or "Incomplete" addresses were collected as a result of improved efforts in patient data collection, the City would realize $65,345 in additional revenue each year. We believe a one percent increase would be modest.

Conclusions

EMS personnel collect patient medical and billing data on a Patient Care Report (PCR) at the scene of an EMS call. Such data becomes the basis for billing the patient for EMS services. PCRs with incomplete or inaccurate billing data are classified as non-billable.

In FY 2000-2001, $6,534,492 in accounts were identified as non-billables and classified as "Bad Address" or "Incomplete Address" based on incomplete or inaccurate billing information in the PCR.

The Fire Department should be able to collect additional revenue by encouraging EMS personnel to collect complete and accurate billing data on the PCR and by forming agreements with receiving hospitals with regard to patient billing data, as permissible by law.

The Fire Department should provide training for EMS personnel regarding the completion of PCRs as well as monitor the completion of PCRs and make the provision of complete, accurate billing data a key component of performance evaluation. The Fire Department should attempt to form agreements with receiving hospitals for the exchange of patient billing data.

Recommendations

The Fire Department should:

4.3.1 Work with AIS to monitor the completeness and accuracy of PCRs for billing purposes and have a supervisory Fire Department employee periodically sample and review incomplete PCRs. If patterns of EMS personnel who consistently do not collect accurate, complete data become evident, sanctions should be imposed and such personnel should be trained and coached. The Department should strive to make the collection of patient billing data a key part of employee performance.

4.3.2 Direct AIS to provide training on collecting accurate and complete patient billing data. Such training should focus on specific problem areas that AIS notes in its continuous reviews of PCRs.

4.3.3 Direct AIS to conduct on-site (at the Fire Department) research as soon as a PCR is identified as "Incomplete Address." Such research may aid in collecting more complete patient billing data and classifying fewer accounts as non-billable. Further, the Department"s contract with AIS should specify precisely the steps that AIS will take with regard to subsequently researching accounts that lack sufficient billing information. The contract should require that AIS document each research step it takes.

4.3.4 Negotiate agreements with hospitals receiving patients that stipulate that the hospitals will provide patient billing data to the Fire Department upon request as permissible by law.

Costs and Benefits

The recommendations would require staff time and effort for research, training and negotiating but would not likely require any additional expenditure of funds. The recommendations could, however, provide significant benefits if the volume of non-billable accounts are reduced.

In FY 2000-2001, $6,534,492 in patient accounts were classified as non-billable due to incomplete or inaccurate billing information. We believe the above recommendations could aid in converting some of these accounts to billable accounts and therefore increase EMS revenues. By collecting one 5 percent of the accounts currently classified as non-billable, an additional $326,725 would be collected annually. We believe such an increase is modest.