Is there a State Protocol about passing other hospitals to transport a patient to a hospital out of the area? For example, the patient wants to be transported to a hospital 26 mile away, to get to that hospital we have to pass 4 other hospitals that are a maximum o 5 miles from the scene. Thanks for any input.

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Marty

PA Protocol states to transport the Patient to the closest appropriate facility.  If the Patient could not be definitively treated at the closer hospitals (i.e. no cardiology for MI or no neurology for stroke)  it is more than appropriate and encouraged to transport to the other facility.  Now, the tricky part.  I have also understood and abided by the rule, if the Patient has a specialist at the more distant hospital, then yes that too would be appropriate as long as their current problem is related to that.  Continuum of Care.  It is also appropriate to notify the Patient that their insurance, may not cover the additional mileage if the definitive care is closer.  I am not a billing agent and only have a vague knowledge of the complex rules for ambulance payment. 

I live in rural PA and often bypass 2-3 hospitals to get Patients to Speciality Care Centers and know of few issues(mostly on the billing end).  

The patient has the right to choose their facility (within reason).  THEY get to choose, not you.  You get to RECOMMEND - and their decision must be informed.  Our national EMS law firm is right there in PA - Page, Wolfberg and Wirth - and they have a form that they recommend for use if EMS thinks that the patient should go to A and the patient insists to go to B.  ("Within reason" means that if your patient in PA requests to go to California, you're probably within reason to say "we can't do that.")


"Billing problems" should not be part of the thought process for field EMS providers.  We should do what is right for the patient, and let others sort that out afterward.  In our service, other than accurately and completing a PCR, we never discuss billing with field personnel.


"Protocols" only come in to play to advise you what to advise the patient, or if the patient is unconscious etc.

Yes, there is a protocol that addresses the issue; sort of. The protocol in question actually addresses the issue of by passing lower level community hospitals to transport a patient to a specialty care center such as a trauma center, pediatric facility, PTCI (cath lab) capable hospital etc... The protocol is found on the PA Dept of Health website at

http://www.portal.state.pa.us/portal/server.pt/community/emergency_...

Then click on 'BLS protocols' The first section you will want to read is 180 were it talks about trauma triage destination, then it also discusses MI's and strokes. Generally it states that if your patient needs a specialty center and the time to get them from scene to spec ctr is 45 minutes or less then take them by ground, if it is more than 45 minutes consider air medical evacuation (helicopter). If air medical is not available then transport to closest 24 hour ER for stabilization and eventual transfer.

Now, when it comes to patient choice, that is the patient wants to go to hosp xyz because they like the nurses there, and it is 30 minutes away and you are bypassing 4 other hospitals in the process, then perhaps EMS is not the best mode of transport for the patient (ie: not acutely ill). I would run these requests by your supervisor because if you are a 911 truck and you are going way out of your district to run granny to the next county and leaving your area uncovered than that could become and issue. If you are at level 0 (meaning there are no ambulances available in your area) then it is entirely acceptable to take them to the closest ER despite the patient's request (remember you are an EMS unit, not a taxi). If your frequent flyers don't want to go to the local yokel ER then they will probably stop calling 911 for what is essentially a taxi ride.

Also, if one particular patient seems to be doing this to you guys  a lot then getting your medical director involved (with your bosses' permission of course) can be helpful as perhaps a case manager needs to get involved to see why they are going to the ER for seemingly minor issues that could be better dealt with in home health care

Hope this helps,

Sincerely,

Justin Poland A.A.S., NREMT-P, LP, EMS-I

Great point about billing, although we are not EMS billers we are EMS providers, if a patient is requesting to go to ER C and you are bypassing ER's A and B to get there then having them sign an ABN (Advanced Beneficiary Notice) would make your billing lady jump for joy. Ill tell you why... Medicare (which sets the standards for which pretty much all insurance claims are processed) states that if a beneficiary request EMS transport for a non emergency condition (as indicated by your assessment) and /or you by pass a appropriate facility for patient choice, then Medicare requires the EMS agency to have the patient sign an ABN BEFORE transport; we cannot get it later, if we don't then medicare can refuse to pay for the base rate (or excess mileage) as the case may be. Your  documentation is key here, if your patient bypasses three hospitals to go to city cardiac center, and they have a heart condition that is being treated by a specialist there, and their complaint is reasonably related to their heart condition, then in your narrative on you PCR it should say something like "Patient requires cardiology specialist treatment not available at closer facility due to heart palpitations, chest pain, nausea,etc...."

Hope this helps,

Sincerely,

Justin Poland A.A.S., NREMT-P, LP, EMS-I



Earl Culvey said:

Marty

PA Protocol states to transport the Patient to the closest appropriate facility.  If the Patient could not be definitively treated at the closer hospitals (i.e. no cardiology for MI or no neurology for stroke)  it is more than appropriate and encouraged to transport to the other facility.  Now, the tricky part.  I have also understood and abided by the rule, if the Patient has a specialist at the more distant hospital, then yes that too would be appropriate as long as their current problem is related to that.  Continuum of Care.  It is also appropriate to notify the Patient that their insurance, may not cover the additional mileage if the definitive care is closer.  I am not a billing agent and only have a vague knowledge of the complex rules for ambulance payment. 

I live in rural PA and often bypass 2-3 hospitals to get Patients to Speciality Care Centers and know of few issues(mostly on the billing end).  

Justin, I think you may have over-analyzed the Medicare ABN rules.  What you describe as a non-emergency call is correct, but what is a non-emergency call?  "Non-emergency" is determined at the time of dispatch, by the route of arrival of the call.  Only a call classified by MPDS as "Omega" would fit in to that category.

A call that comes in via 911 or the local equivalent is an emergency call- regardless of the acuity.  It may be a low-acuity emergency, but ABNs are not required for these calls.  If you're picking the patient up at an assisted living facility, or nursing home, then the ABN is a good idea.

Hey Skip, I see your point on this one but its factually inaccurate. Medicare doesn't define an 'emergency' by what number a patient called to get an ambulance. It doesn't matter if they called 911, a seven digit number, or a 1-800 number, it is based exclusively on the patient's condition at the time of EMS assessment. While the EMD information can be used to appeal a denial by CMS, it carries very little weight. Medicare regulations state even if a person calls 911, and the patient's condition is stable at the time of EMS assessment, and alternative transportation could be used to get the patient to the ER without endangering their health or safety, than CMS wont cover the trip.

The following booklet from CMS gives several examples of what is and isn't covered.

http://www.medicare.gov/Pubs/pdf/11021.pdf

Specifically medicare determines if something is emergent by looking at the EMS providers assessment and determining if the patient's condition falls into any one of the emergency condition code criteria. For example if Mr Smith falls in his front yard and hits his elbow and knee, his wife calls 911 and EMS arrives, assesses Mr Smith and determines that he can bend his knee, albeit with 4/10 pain and he is conscious, alert, not in shock, and doesn't appear to have a fracture or dislocation and could go by private car; then medicare wont pay for the service and an ABN is a good idea. Although its not required by CMS to give an ABN on a 911 call where the EMS crew believes that the patient could safely go by private vehicle, its a good idea and what Medicare refers to as a 'courtesy ABN'. The ABN is only required on non-emergency transports so in that regard, I stand corrected.

My experience with this is very different than yours, Justin.  Sorry I'm not willing to do the research and write an expose on the topic, but there is guidance out there somewhere that says when an ABN is to be used, and they are never required on 911 calls.

Actually, I found the support for what I said, from CMS, very easily.

http://www.cms.gov/Outreach-and-Education/Medicare-Learning-Network...

Issuance of the ABN is mandatory if all of the following 3 criteria are met:
1. The service being provided is a Medicare covered ambulance benefit under Section1861(s)(7) of the Social Security Act (http://www.ssa.gov/OP_Home/ssact/title18/1861.htm) and
regulations under this section as stipulated in 42 CFR 410.40-.41

2. The provider believes that the service may be denied, in part or in full, as “not reasonable and
necessary” under Section1862(a)(1)(A) for the beneficiary on that particular occasion; and
3. The ambulance service is being provided in a non-emergency situation. (The patient is not under duress.)
Please note the emphasis.  In fact, CMS has stated elsewhere that issuing an ABN in an emergency situation would be coercive, and therefore inappropriate.



Skip Kirkwood said:

Actually, I found the support for what I said, from CMS, very easily.

http://www.cms.gov/Outreach-and-Education/Medicare-Learning-Network...

Issuance of the ABN is mandatory if all of the following 3 criteria are met:
1. The service being provided is a Medicare covered ambulance benefit under Section1861(s)(7) of the Social Security Act (http://www.ssa.gov/OP_Home/ssact/title18/1861.htm) and
regulations under this section as stipulated in 42 CFR 410.40-.41

2. The provider believes that the service may be denied, in part or in full, as “not reasonable and
necessary” under Section1862(a)(1)(A) for the beneficiary on that particular occasion; and
3. The ambulance service is being provided in a non-emergency situation. (The patient is not under duress.)
Please note the emphasis.  In fact, CMS has stated elsewhere that issuing an ABN in an emergency situation would be coercive, and therefore inappropriate.

I agree with you entirely, the question is what do we consider an emergency? Medicare has a different view of this than the general public. To many people if you bang your knee and it hurts that's an emergency; medicare would say that in order for that to be an emergency there needs to be something about the patient's actual condition (as determined by assessing vitals, physical exam, subjective complaint etc...) that would make the patient in a condition of 'duress' CMS does not define duress as an EMD code or a hangnail.

As we move towards single payer healthcare there is going to be an increasing emphasis on cost containment, and things like the sprained ankle, skinned knee, or the 'I can't breathe' (because they have sinus congestion) are going to be increasingly scrutinized and increasingly, denied for payment.

So, according to CMS, if someone calls 911 and you get there and the patient is not in duress, stable, and reasonably capable of being transported by other means (ie private car) that would be a non-emergency.

In these circumstances it would be a great idea to provide an ABN to the patient if they insist on transport, although it would not be required--yet



Skip Kirkwood said:

Actually, I found the support for what I said, from CMS, very easily.

http://www.cms.gov/Outreach-and-Education/Medicare-Learning-Network...

Issuance of the ABN is mandatory if all of the following 3 criteria are met:
1. The service being provided is a Medicare covered ambulance benefit under Section1861(s)(7) of the Social Security Act (http://www.ssa.gov/OP_Home/ssact/title18/1861.htm) and
regulations under this section as stipulated in 42 CFR 410.40-.41

2. The provider believes that the service may be denied, in part or in full, as “not reasonable and
necessary” under Section1862(a)(1)(A) for the beneficiary on that particular occasion; and
3. The ambulance service is being provided in a non-emergency situation. (The patient is not under duress.)
Please note the emphasis.  In fact, CMS has stated elsewhere that issuing an ABN in an emergency situation would be coercive, and therefore inappropriate.

If you start down the ABN road in the 911 world, you're asking for trouble.  it's not required now, so please don't start.

If you disagree with me, contact the lawyers at PWW in Harrisburg.  I'm pretty sure that they will give you the same advice. 

And in most states, the definition of emergency is covered by the "prudent layperson" statute - and in the federal world too (via EMTALA and the BBA of 1997) - for a definition of prudent layperson, it's laid out pretty well here:  http://www.pugetsound.va.gov/docs/prudentlaypersonfactsheet.pdf

So far, all the case law seems to say "If a layperson calls for emergency help, it's an emergency."

Contrary to cost-containment philosophy, but the "state of the art" today.

Before making a field judgement on what CMS may or may not consider an emergency based on what it is that you write in in your documentation, don't forget that you may not be dealing with CMS at all with Medicare billing. There are many, many varieties of coverage involved with Medicare, many of them that do not pay providers directly for Medicare recipients care.

Given your concern about cost containment, were you able to verify the participating (or in network) status of the 'closer' facility for the particular flavor of medicare? A hundred bucks or two in mileage charges may cost your patient three or four times that in out of network fees or increased copays at non participating facilities.

Even on the interfacility transfers these days, the complexities of whom pays for what in any given situation can extend far beyond the grasp of your billing office. Some skilled care (inpatient post acute SNF/Rehab) services are now paid for as part of the inpatient hospital stay, meaning short of a without a doubt unstable patients should go back to the originating facility.

While I can't cite occurrences, think of the logic of your argument for completing an ABN (which you really needn't do on emergent dispatches) . You are attaching a document that flat out says that the response may be considered non emergent. Hey, the ambulance crew told them it wasn't an emergency, lets deny the claim all together.

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