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 w
es, 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.


  • RevMedic says:

    Great post, Peter – very insightful. Yes, billing is becoming more and more important. My agency gives out performance pay based on 5 variables: dry run rate (the lower the better); number of transports (the higher the better); response time (the lower the better); collection rate (the higher the better); and a 5th variable that changes from month to month. It might include IV success rate, number of out of town transports, etc. The collection rate is culled from the past 6 months or so. We’ve been told that much of that rate depends on us – obtaining (electronic) signatures at the time of call, copies of insurance cards, complete charts documenting the chief complaint, etc. We used to joke about having a credit card machine attached to our charting computers, but I honestly think it could be a reality. Our agency has a saying: “We don’t go on calls so we can bill, we bill so we can continue going on calls”.So how is the offspring?Take care.

  • Terrier Andy says:

    Wow. I knew that paramedics in the US are paid out of medical insurance, but I’d never realised just how big a bug-bear it is for you guys.Over here in the UK, the NHS (though poorly funded by the government and often miss-managed) takes care of everyone and anyone, to a certain extent.Make you wonder, which is the better care: Private medical insurance, or the more public National Health Insurance?Interesting thoughts…Brilliant blog by the way, keep writing!TA7

  • Anonymous says:

    What a way to live in our world! From previous experience know the pressure to pull in the bucks- didn’t matter if we came across as money hungry- was defined as we cater to the elite- but that just doesn’t wash- what bull crap! You’re doing the right thing- the PATIENT comes first- keep up the good work!

  • Brendan says:

    This brings up one thing I do like about my state system- by state law, EVERYBODY resupplies out of the hospital. You use it, they have to give it to you. Levels the playing field considerably, and ultimately I believe, results in better care. Because most services only transport to one or two hospitals, and therefore have that hospital’s IV tubing on their truck- the nurses don’t have to waste time swapping out the IV bag and line because it doesn’t match their pumps. When I worked for a commercial service, I kept my truck stocked with two sets from every hospital in my area (we obviously transported to more hospitals than the fire departments). I could usually even have their particular IV lock on the end of the line.

  • PC says:

    Thanks for the comments –Revmedic- I like the incentive idea. I have heard our company is considering reinstating the old dollar for billing information plan. positive feedback always seems to work better than no feedback. By the way, the baby is great!Terrier Andy- Every now and then there is talk of nationalizing our health insurance, but it is largely a nonstarter. Too many entrenched monied interests. I hadn’t thought about its impact on EMS. Here, everyone gets transported, money or not, but they all get a bill, insurance or not. Just many of the bills end up as uncollectable.Annonymous – We try to keep the patient first, and the bill second. We just are being reminded not to forget about the bill after we’ve taken care of the patient.Brenden- We used to resupply at the hospital as well, which worked great, but then there was concern on the part of the hospitals that it represented a kickback in return for business so most of the hospitals around here stopped doing it. The mismatching saline locks are a huge waste. Like you, I used to keep two different sets on the truck.Thanks again for the comments.PC

  • Brendan says:

    Yeah, the kickback thing sucks- just ask the hospital-based ALS services in NJ. But somebody should’ve told the hospitals that Medicare already issued an opinion on that. As long as the EMS service doesn’t bill for the supplies, and the hospital exchanges on a 1:1 basis, it’s all legal. There’s a specific Safe Harbor for it. Our state law requires that the crew complete and sign a form indicating what supplies and in what quantities they are taking. By signing, the crew’s service agrees not to bill for anything on the form.

  • Brett says:

    Peter once again you hit the nail on the head! This is a very good way of putting our current situation with billing. I would like to copy and post your entry on our union website if thats ok with you

  • Anonymous says:

    The billing people at my employer have this brick wall mentality. They think we’re not supposed to know what it costs for an ambulance transport and don’t want us worrying about costs, as if it were to unduly influence our care decisions. But reality is that, as the one who delivers services, I ought to know and be able to tell people with some reasonable accuracy what it will cost. I also ought to know what supplies cost so I can remember not to waste them.I started putting a lot more effort into getting an IV on diabetics, for instance, when I found out that Glucagon costs something like $100 per dose at the wholesale level. Not to mention what we charge. D50 and IV supplies comes in at about $4. Maybe the get billed as the same, but one costs us $96 less per dose. So a few extra minutes of careful IV work might mean that we make a little more money on this call, or, more likely, lose way less money when the bill goes unpaid.I might not put pacer pads on a patient as quick as I once was when I find out they’re $30 a piece. It only takes a second to rip out the pads if I need them instead of the prophylactic use of them like I did in the past. Maybe I pay attention to the IV bags and drugs. Use up the ones closest to expiration first so we don’t waste so many supplies that are expired. Little things like this make a big difference when you run 90,000 calls a year.Our reimbursement rate sucks. It’s about 40%. So 60% of our patients aren’t paying their bills. And management at my company, which is a non-profit, has this attitude like they need to keep the cost issue hidden. The reality is that I have a lot of control in cutting costs. Maybe I am more judicious about my use of supplies. Maybe I more strictly follow protocol or use good clinical judgment as to the medical necessity of an intervention. People start thinking that being cost conscious is “rationing” when in fact I’m not withholding medically necessary care, only doing the necessary care in a cost effective way.I don’t understand this rationale in EMS that the costs need to be hidden from the people actually providing the billable services. It’s not helpful.

  • About this blog... says:

    i hear your pain. we use laptops for our trip reports and now have to get patients to sign their name on our laptop screen. this creates several problems…one, because most people (it seems) don’t understand how to sign on a computer screen – i’m always having to tell people to not click the pen on. two, the print is so small that many people (especially the elderly population) can’t read it. three, while we might have the billing script in different languages, we don’t know how to tell people in different languages what we want them to sign and why. last, but not least, the computer used to be something we touch and no one else…well, ignoring the mrsa that crawls on it when we set it down in a hospital. but regardless, now we have patients touching the computer and it’s a germ nightmare. seems like now we get in more trouble if we don’t have a patient sign as compared to if we cause medical harm to the patient.rant over!by the way, i just linked to your blog on my fairly new one…you might like it: kind of a new year’s resolution of sorts…finding the funny stuff out of each shift.

  • DH(AHA)PD says:

    sorry about the weird username above – just fixed it!(formerly “about this blog”…)

  • DH(A HA)PD says:

    and to anonymous above – we run about 80,000 a year and our reimbursement rate is just below 30%. imagine the pain i feel! :(the system is broken and i think that getting people to sign something doesn’t mean they’ll get any more money out of them – people sign hospital billing documents all the time and the collection rates are still bad.

  • Anonymous says:

    “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.”RIGHT. Instead they are just going to increase your property taxes each year and charge you for the service, whether you use it or not.

  • Anonymous says:

    That’s one thing that always bugs me… the perception that collecting insurance information makes us “money hungry” and that “we care about our patient first, not about billing”. To me, caring about getting accurate and complete billing info IS caring about our patient. If I can do everything I can do to make sure the patient doesn’t get a bill from our company, I will. They’re usually bad off enough without having to worry about getting a big charge from us. We’re not collecting signatures so we can bill the patients, we’re collecting them so we don’t have to, and can bill the insurance instead. I guess it all depends how you look at it.

  • Lucian says:

    Peter-First of all, I’m glad I found your blog by chance (linked from “On the Clock”, I’m one of “Sam”‘s partners). I read both of your books about two or three years ago when I was still a basic EMT.Billing kills me. We just got new forms where I work, and now instead of just being able to either have the patient sign or writing PUTS “patient unable to sign” we have to have the patient sign plus a witness and the crew sign, or if the patient is unable to sign, we have to have the patient’s facesheet from the ER, an ER nurse’s signature, and signatures of the entire crewWhat a hassle. Its not like we get any money from the billing programs anyway, so what does it really matter? On a final note, you can check out my blog, I’m linked on “On the Clock” as “Virginia EMT”.Thanks for your writing!Lucian

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