The Audit notes several perceived inefficiencies in the EMS Patient Billing Data collection practices. The Department, while recognizing that improvements in any system are always possible, believes that every effort is already being made to collect complete, accurate, and useable patient billing information. EMS Division staff meet regularly with the EMS revenue collection experts at Allied Information and Services, the billing contractor, to ensure that Department policies and procedures are designed to maximize revenue collections. Most of the changes that were recommended by the Audit have either already been completed or have been studied and were deemed impractical.

EMS personnel are encouraged by the Department and they are required by law to acquire as much information as possible regarding their patients. Often, patients are homeless and do not have addresses to relay to the paramedics. Many of the people our service encounters do not have or cannot afford insurance of any kind and therefore do not have insurance ID cards. People are sometimes unable or unwilling to provide personal information during the stress of a medical emergency. Nonetheless, the Department and its billing agent Allied Information and Services make every effort to aggressively collect revenues that are legally owed to the City for services rendered.

· Recommendation of Auditor"s report

4.3.1 Work with AIS to track the completeness and accuracy of PCR"s for billing purposes and have a supervisory Fire Department employee periodically sample and review incomplete PCR"s. 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.

· Assessment of Department

The Department concurs with the recommendation of the audit.

Staff from the EMS Administration Section routinely work with Allied Information and Services to maintain the highest possible level of information collection.

The Audit refers to two tests that were conducted related to patient care reports. The first, a test of timeliness of billings, found that all patient care reports were promptly received and accounted for. This is a proof of the efficiency of the EMS Division Administration Section and its close working relationship with field crews.

The second test evaluated incomplete and bad address accounts. Not surprisingly it found that "...patient name and birth date were the most frequently collected data points", in regards to patient identifying information. This is because judging a patient"s response to "what is your name?" is a tool frequently used by paramedics to ascertain their patient"s level of consciousness. If a patient does not know his or her name, chronic and/or organic causes notwithstanding, their mental status, their perfusion, their cerebral/cardiovascular output may be in jeopardy. Such a situation would increase a paramedic"s index of suspicion for illness or injury. A patient"s birth date is the second critical information point for paramedics to obtain. A patient"s verbalized age frequently differs greatly from the patient"s calculated age.

Other billing information, such as residential address, social security number, insurance information and home telephone number are reported to be "...not necessarily correct... This appears to indicate a need for greater emphasis on the collection of accurate patient billing data". The accuracy of the billing information is dependent upon the person providing that information. The members of the public whom our paramedics encounter during the course of a typical shift are not always rational, coherent, clear-thinking people during their EMS interaction. These people are patients or they are family members. They are upset, stressed, fearful, in pain, over-whelmed, and sometimes angry. It is very difficult to gather accurate data under these circumstances.

Details such as street addresses, social security numbers and the like are usually inaccurate as a function of the source, not of the collecting agent.

The report of the auditor states"...Several fire department officials...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 jobs¹". The report goes on to state that "...as a result, accounts that are currently ...non billable may, in fact, be billable to a third party payer²...".

The City and County of San Francisco does not impose ad valorem taxes on its citizens and visitors. As a result, emergency ambulance services fee schedules are reviewed and approved by the Board of Supervisors. EMTs and paramedics receive regular and ongoing training in the need for accurate data collection to meet the Department"s legal responsibility for revenue collection. Some members of the department may philosophically disagree with the City"s health care revenue policies. The comments the Audit personnel heard may have been based on rumors or vented feelings. There is no direct evidence that Department personnel fail to provide billing information based on their opinions related to health care billing practices.

Allied Information and Services maintains a full-time employee on site at the EMS Administration Division. Chart audits, spot checks, data collection are all done routinely as part of the medical/clinical oversight and CQI/Research activities. The EMS Division tracks all incidents to ensure that all charts are completed.

Letters are sent by the EMS Chief to any field personnel who do not submit reports in a timely fashion. AIS provides written reports to the EMS Division regarding the completeness of reports received from field paramedics. Documentation patterns are tracked and crew performance addressed in a timely manner by the EMS Division staff. The EMS Division is planning to utilize the CQI loop of policy development, training, and field supervision to improve the accuracy and completeness of charts. A new training bulletin has been prepared related to patient care report documentation issues.

The Department agrees that the capture of accurate information on patient care reports should be emphasized during employee performance reviews. The chart audits and documentation reviews to which the Audit refers are already done on a regular basis. EMS Division staff currently sample patient care reports for accuracy and completeness. The CQI/Research office regularly samples and audits field charts for accuracy, thoroughness, completion, patient information and clinical statistics. Deficiencies are identified and patterns are recorded. Personnel who display consistent problems are identified, contacted either by telephone or in person and counseled by a Rescue Paramedic Captain.

The Department plans to expand this program to better utilize information currently provided by AIS that identifies crews with higher than normal documentation errors. However, many factors contribute to the reporting of incomplete or erroneous information. Information may be unavailable to those at the call site, patients or relatives may be physically unable to provide information, or patients who are members of the homeless population may lack usable billing information. Employees who work in certain areas of the City may provide services to patients who are more frequently unable to provide accurate billing information. The use of sanctions against personnel with documentation errors above baseline must be carefully considered on a case by case basis.

The Department strongly feels that it is essential to utilize personnel with paramedic training to audit Pre-hospital Care Reports. Most of the information and style of documentation on a patient care report requires specialized training and field experience for proper evaluation. State Health and Safety Code Title 22 mandates that Quality Improvement and Pre-hospital Research be conducted by Mobile Intensive Care Paramedics. Post-incident evaluation and retrospective chart auditing are unique skills, ones best performed by field-experienced, academically minded clinical officers. The CQI & Research Paramedic Captains are the Administration Clinical Officers for the San Francisco Fire Department.

· Department Action Plan and timeline

The Administration Section of the EMS Division will continue to work side-by-side with AIS personnel to provide complete and accurate information for billing purposes. The new documentation training bulletin will be distributed as part of the winter EMS In-Service training. Field supervisors will be provided with copies of AIS reports to provide feedback to field crews with documentation performance problems. The Department will continue to use EMS supervisory personnel to sample patient care reports and provide feedback to field personnel as part of the employee performance evaluation process.

· Recommendation of Auditor"s report

4.3.3 Direct AIS to provide training on collect accurate and complete billing data.

· Assessment of Department

The Department concurs with the recommendation of the audit.

The Department will continue to utilize Allied Information and Services as a resource to ensure that field personnel have the latest tools and skills related to documentation and billing information collection.

The Audit states that "AIS reports that it last provided training on completing PCR"s several years ago. More such training should take place." The Audit appears to have misunderstood the meaning of this statement. EMS Division personnel do work closely with AIS staff to share information on billing practices and the Department supports maintaining that relationship. AIS personnel were likely referring to the fact that under their contract they are not responsible for conducting large scale training for field paramedics.

The EMS Division CQI/Research staff, in coordination with EMS In-Service Training, is responsible for and has consistently provided training for EMTs and paramedics on proper documentation and information collection.

Over the last several months, a training manual for completion and use of the Field Medical Report (PCR) has been developed and is ready for implementation. Consistent with the Audit recommendation, this training manual was developed by EMS Division personnel with input from AIS staff to ensure that there is a focus on the specific problem areas identified by AIS. A department-wide training module, incorporating documentation and data collection, had been planned for execution during the month of September 2001. The events of Tuesday, September 11^th preempted all training and shifted all focus to Mass Casualty Incident and Disaster Preparedness. The EMS In-Service Training Section plans to implement the documentation module in early 2002. These lectures will reiterate, reemphasize and refresh skills and knowledge already acquired through participation in In-Service and EMS Academy programs.

· Department Action Plan or Timeline

The Department will continue to utilize Allied Information and Services as a resource to ensure that its personnel have the latest tools and skills related to documentation and data collection. The Department will provide training in documentation and data collection as part of its regular EMS training in early 2002.

· Recommendation of Auditor"s report

4.3.4 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 collection 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 regards to subsequently researching accounts that lack sufficient billing information. Further, the contract should require that AIS document each research step it takes.

· Assessment of Department

The Department will analyze the recommendation of the audit.

The Department supports exploring expanded use of Computer Aided Dispatch (CAD) data searches by EMS Division personnel when practical to assist in gathering billing information.

The Audit states that "...the PCR should be compared to the CAD data.³" This recommendation is based on an assumption that CAD data reports consistently include accurate information on the home address of patients.

While comparing CAD reports to patient records may have some benefit to revenue collection, there are a number of practical limitations to this process. The Computer-Aided Dispatch System is access-protected. Only a select group of sworn department officers and civilian employees of the Emergency Communications Center have access to the machine"s functions. AIS civilians should not be given authorization for real time access to the sensitive information contained in CAD data banks solely for billing purposes. Additionally, experience has shown these types of searches to be extremely labor-intensive, time consuming and often yield little return for the effort.

CAD reports are not always an accurate reflection of the patient"s billing information. For example, an address complete with street number and name reflects where the patient was encountered but not necessarily where the patient actually lives, thereby voiding the CAD data as representing a viable billing location. Another example is that the CAD may lock on a street box or a firebox that is auxillarized to a confirmed address. This address may be a bank, a grocery store or a hospital building. Again, invalidating the information for use as a revenue-generating site.

Currently, searches for missing data are undertaken as soon as possible following identification of missing information under an umbrella of cooperation between AIS, the EMS Administration Section, and the ambulance Receiving Facilities.

The Department will meet with AIS to review the possibility of developing a series of specific steps that will be taken to identify incomplete billing information.

· Department Action Plan or Timeline

The Department, in cooperation with Allied Information and Services and with the Receiving Facilities, makes every effort to research and accurately relay viable billing information. The Department will investigate the use of dispatch computer data and the development of research steps to assist in billing practices and expects to complete this analysis by July 2002.

· Recommendation of Auditor"s report

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.

· Assessment of Department

The Department concurs with the recommendation of the audit.

California Civil Code Section 56.10 (c) authorizes providers of health care to share billing data. AIS and the Department have verbal agreements in place with all of the County"s Ambulance Receiving Facilities for the free exchange of patient billing information. At any time, AIS or the EMS Division Administration Section may contact any of the hospitals to request, confirm or exchange billing information. To date, neither AIS nor the EMS Division has encountered any problems, hostilities or denials with or from any receiving hospital when requesting patient billing information

The department is concerned over the statement that "...AIS finds that it is often difficult to get hospitals to provide a response⁴". Hospital billing departments tend to be extremely busy, chronically understaffed and frequently have difficulty providing a rapid response to information requests. Ultimately, all requests for information are honored and all available data is provided to the billing service.

· Department Action Plan or Timeline

The Department will review the existing hospital agreements and propose changes as necessary. The Department will continue to cultivate positive relations with all parties consistent with the agreements and contracts for the exchange of patient billing information. The Department expects to complete this review by July 2002.

IMPORTANT NOTE

New State and Federal regulations were recently passed as part of the Health Insurance Portability and Privacy Act. The new legislation sets stringent regulations for the protection of patient confidentiality. The regulations also require complex release agreements for the use of patient care report information for billing purposes. The new HIPPA laws also require the development of new agreements and contracts between health care providers and billing agents.

¹ Management Audit of the San Francisco Fire Department, 2001, pg. 4.3-4

² ibid., pg 4.3-4

³ Management Audit of the San Francisco Fire Department, 2001, pg. 4.3-5

⁴ Management Audit of the San Francisco Fire Department, 2001, pg. 4.3-6