The Lifecycle of an EMS Claim

The Lifecycle of an EMS Claim

EMS agencies are always standing by, ready to respond to emergency medical needs. For municipal agencies, this readiness is often funded by tax dollars. However, funding for readiness is often not sufficient to cover utilization costs. That means there is a price for having an ambulance ready to run and different costs to keep the ambulance running on every call. Reimbursement generated from billing EMS claims is how EMS agencies afford staff, equipment, and necessary tools for emergency health treatments.

EMERGICON’s teams are experts in processing claims compliantly and efficiently. Here is the lifecycle of a claim at EMERGICON. 

Step 1: Starting the claim process

The Pre-Billing Department is the first to handle a patient care report (a.k.a. claim or ticket) that arrives at EMERGICON. At this stage, the Pre-Billing Specialists check the patient’s data, find their healthcare coverage (MedicareMedicaid, Commercial Insurance), and confirm at least three matching pieces of information about the patient. 

If there is missing or mismatched data, the process gets delayed. In complex cases, like unconscious patients, the team may need to take extra steps to locate all the required information. In these scenarios, the Pre-Billing Assistants (PBA) call the hospitals on behalf of our clients to find any pending information. 

Step 2: Finalizing and forwarding the bills

Once the required information is compiled, the Billing Department receives the data about the patient’s demographics and healthcare coverage. Then, the team assesses each claim considering the following factors: who is the payer, what happened to the patient, and how is the billing structure of the EMS agency that performed the claim’s referred run. 

With that information, the Billing Specialists set the bill according to the payer’s requirements. The goal is to finalize and forward compliant bills that will get paid without an issue. Cases like non-emergent EMS runs require additional documentation to reinforce to the payer that they must pay for that service. 

Step 3: Checking on pending bills 

In a perfect scenario, after receiving the bill, the patient’s insurance provider or other healthcare coverage pays for the charge. However, not every case is like that. 

The Accounts Receivable Department works on rejected tickets or claims sitting for longer than 30 days. The AR Specialists pull reports and review the documents to discover why the bill is pending and solve the issue.

Many reasons could explain a pending or rejected claim: a simple demographic error, information that is not updated, or a failure to meet specific documentation requirements. When necessary, the AR team members contact the identified payer to verify the problem. If there is a denial, it’s time to work on an appeal.

Every healthcare coverage has its timeline for payments, revisions, and appeals. The EMERGICON teams understand hundreds of insurance guidelines and billing processes.

Step 4: Posting the payments

After the healthcare coverage pays the bill, the Cash Applications Department posts the payments in the system and reconciles the claim. When appropriate, the Cash Application Specialists also bill the balance, if any is left. 

The balance can be billed to a private patient or a second insurance provider. For example, a patient may have Medicare and Commercial Insurance coverage.

Step 5: Mediating private patient claims

The Patient Accounts Department often acts as the final step of the claim cycle. When a claim gets to this stage, it’s a private patient pay, or it has changed in the system from insurance’s responsibility to patient’s responsibility. In both cases, the Patient Account Specialists contact the patient to discuss the balance remaining on the account.

The team handles all the patient’s correspondence and calls, such as questions, complaints, and negotiations. EMERGICON is always thoughtful with the patient’s economic situation. When authorized by the EMS provider, the team sets up payment plans or offers discounts to facilitate the payment of the bill. As you can see, the journey of an EMS claim can be simple and straightforward, or it can take many twists and turns. At EMERGICON, we pride ourselves on understanding the details of each step and providing excellent customer service along the way to the EMS agencies we serve and their patients.

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