Infographic | What Does the CMS COVID-19 IFR Mean for EMS?
Looking for highlights from the new CMS IFR? See below for an infographic! (Members, read Kathy Lester, Esq.’s comprehensive summary.)
CMS Waives Restrictions on Ground Ambulances During COVID-19 Pandemic
The Centers for Medicare and Medicaid Services (CMS) promulgated an interim final rule with comment period (IFC) entitled “Policy and Regulatory Revisions in Response to the COVID-19 Public Health Emergency.” Consistent with the recommendations the AAA made to CMS, for the duration of the public health emergency (PHE), the IFC allows ground ambulance service providers and suppliers to transport patients both on an emergency or non-emergency basis to any destination that is equipped to treat the condition of the patient consistent with Emergency Medical Services (EMS) protocols established by state and/or local laws where the services will be furnished. In related guidance, CMS has suspended most Medicare Fee-For-Service (FFS) medical review during the emergency period due to the COVID-19 pandemic, waived patient signature requirements, and is pausing the Repetitive, Scheduled Non-Emergent Ambulance Transport Prior Authorization Model. The policies of the IFC are effective retroactively to March 1, 2020.
On March 11, the AAA sent CMS a letter specifically requesting for the agency to waive during the COVID-19 pandemic the regulatory restrictions that prevent coverage for transport to alternative destinations. Separately, the AAA has been pressing CMS to provide relief from signature requirements. The AAA had also been working with CMS to lifting of these restrictions and others to eliminate barriers the current Medicare regulations in responding to the COVID-19 crisis.
Paying for Transports to Alternative Destinations. During the duration of the crisis, CMS has expanded the list of destinations for which Medicare covers ambulance transportation to include all destinations, from any point of origin, that are equipped to treat the condition of the patient consistent with Emergency Medical Services (EMS) protocols established by state and/or local laws where the services will be furnished.
These destinations may include, but are not limited to: any location that is an alternative site determined to be part of a hospital, critical access hospital (CAH) or skilled nursing facility (SNF), community mental health centers, federal qualified health clinic (FQHCs), rural health clinics (RHCs), physicians’ offices, urgent care facilities, ambulatory surgery centers (ASCs), any location furnishing dialysis services outside of an ESRD facility when an ESRD facility is not available, and the beneficiary’s home.
This expanded list of destinations applies to medically necessary emergency and non-emergency ground ambulance transports of beneficiaries during the PHE for the COVID-19 pandemic. The IFC does not waive the medically necessary requirements for ground ambulance transport of a patient in order for an ambulance service to be covered.
The AAA is working closely with CMS to confirm that patients who require isolation meet the medical necessity requirements.
Suspension of Audits and Relief on Patient Signatures. In guidance released separately, CMS indicates that it is suspending nearly all audits of providers and suppliers for the duration of the PHE.
CMS has suspended most Medicare Fee-For-Service (FFS) medical review during the emergency period due to the COVID-19 pandemic. This includes pre-payment medical reviews conducted by Medicare Administrative Contractors (MACs) under the Targeted Probe and Educate program, and post-payment reviews conducted by the MACs, Supplemental Medical Review Contractor (SMRC) reviews and Recovery Audit Contractor (RAC). No additional documentation requests will be issued for the duration of the PHE for the COVID-19 pandemic. Targeted Probe and Educate reviews that are in process will be suspended and claims will be released and paid. Current postpayment MAC, SMRC, and RAC reviews will be suspended and released from review. This suspension of medical review activities is for the duration of the PHE. However, CMS may conduct medical reviews during or after the PHE if there is an indication of potential fraud.
CMS also indicates in this guidance that a beneficiary’s signature will not be required for proof of delivery, as it relates to durable medical equipment services, during the PHE. In a follow-up exchange with CMS, the AAA has confirmed that this policy of not requiring a beneficiary’s signature also applies to ground ambulance providers and suppliers. The AAA has requested that this clarification for ground ambulances also be provided in a written FAQ.
Pause in the Non-Emergency Prior Authorization Model. CMS has paused the claims processing requirements for the Repetitive, Scheduled Non-Emergent Ambulance Transport Prior Authorization Model, effective March 29 until the end of the PHE. During this pause, claims for repetitive, scheduled non-emergent ground ambulance transports for the COVID-19 pandemic in States in which the model operates will not be stopped for pre-payment review if prior authorization has not been requested by the fourth round trip in a 30-day period. During the pause, the MAC will continue to review any prior authorization requests that have already been submitted, and ambulance suppliers may continue to submit new prior authorization requests for review during the pause. Claims that have received a provisional affirmative prior authorization decision and are submitted with an affirmed unique tracking number (UTN) will continue to be excluded from future medical review. Following the end of the PHE for the COVID-19 pandemic, the MACs will conduct postpayment review on claims otherwise subject to the model that were submitted and paid during the pause.
Telehealth Services. While CMS does not provide authority for ambulance organizations to bill directly for telehealth services, it does modify for the duration of the PHE the “direct supervision” requirements to allow physicians enter into a contractual arrangement with an entity that provides ambulance services to allow the physician to use the ambulance organization’s personnel as auxiliary personnel under a leased agreement. Under such circumstances, the provider or supplier would seek payment for any services it provided from the billing physician and would not submit claims to Medicare for such services directly.
Ongoing work of the AAA. The rule does not address two critical issues: (1) reimbursement for treatment in place and (2) direct reimbursement for telehealth services. The AAA will continue to work with CMS and the Congress to address these issues that are critical to meeting the needs of patients and your community during the epidemic.
AAA Social Media Campaign During COVID-19
Demonstrate the value of EMS in the COVID-19 crisis!
#EMS is on the very front lines of the #COVID19 epidemic. We provide on-demand #mobilehealthcare for the most vulnerable patient populations, 24/7. Help AAA showcase the incredible importance of #Paramedics, #EMTs, and #Dispatchers in the response to this pandemic. Would you please capture a photo of yourselves in action, holding a simple sign? It is essential that we communicate visually with legislators, regulators, and the general public to help them understand the critically important role we play in saving and sustaining lives. #AlwaysOpen #StayHomeForUs
If practical, please consider showing your medics standing apart from one another (social distancing) if they are not in PPE.
COVID-19 Message from President Aarron Reinert
President
American Ambulance Association
Dear Fellow AAA Members,
I write to you today during what we all recognize as an extraordinary time for EMS. As we collectively serve on the very front lines of the COVID-19 epidemic, we know that the most challenging times are still ahead. However, I am heartened by the collective resolve of the members of the American Ambulance Association to provide 24/7 on-demand mobile healthcare, no matter the circumstances.
As President of the Association, I am sharing below a brief summary of the AAA’s activities to support its members in the face of this devastating disease.
COVID-19 Content & Approach
- Coronavirus Working Group—AAA Region III Director Tom Tornstrom, Executive Director of Gundersen Tri-State Ambulance, has been appointed to lead the AAA Coronavirus Working Group. The team includes AAA’s lobbyists, leadership, staff, and members from across the nation. We meet frequently and collaborate constantly to track challenges and find solutions to EMS issues relating to COVID-19 response. Sample topics include:
- First responder safety and wellness
- Reimbursement for alternative destinations, treatment in place, and mobile testing
- Paperwork reduction / waivers
- Advocating for policies in federal legislation that support mobile healthcare and redacting those that can negatively impact the industry
Members will receive updates via our Digest e-newsletter as we continue to make progress on these and other issues.
- Representation in Stakeholder Groups—From CMS to Congress to local mayors, AAA has representatives and members working with legislators, regulators, and officials at every level of government to advocate for EMS. Simultaneously, AAA leaders are working to showcase mobile healthcare’s unique strengths and capabilities for addressing the viral threat.
- Member Newsletter—The frequency of our member Digest e-newsletter has been increased from weekly to near-daily to ensure that we are curating and communicating the most relevant and important information.
- COVID-19 Archive—All AAA posts related to the virus can be found on our website. A COVID-19 resource link has been added to the top navigation of the AAA website for easy access by providers.
Association Events & Operations
- Stars of Life—Out of an abundance of caution, the Stars of Life event in Washington has been canceled. All blocked rooms will be canceled and refunded by the hotel, and all attendee registration fees will be refunded by diflucan. Staff is working on the development of meaningful ways to celebrate 2020 Stars outside of the context of an in-person event.
- Ambulance Cost Education (Cost Collection)—A plan is in place to move ACE Gold cost collection education from face-to-face to an interactive online learning environment. Subscribers can expect additional updates in early April.
- Headquarters—Association staff is all working remotely whenever possible. Staff is adhering to strict health, hygiene, and social distancing. All order fulfillment, mail processing, and other functions have been moved offsite.
Please don’t hesitate to reach out to staff at info@ambulance.org or 202-802-9020 if we can be of any assistance. Thank you again for your service to your communities during this very difficult time.
Aarron Reinert
President, American Ambulance Association
COVID-19 Coronavirus EMS Advisory 1
This guidance is written to offer American Ambulance Association members the situational background and a list of resources and websites with which to draw guidance and further updates on the latest situation with COVID-19, colloquially referred to as “Coronavirus.” Key information for this update has been drawn from the NHTSA EMS Focus series webinar What EMS, 911 and Other Public Safety Personnel Need to Know About COVID-19, which took place on February 24, 2020. The on-demand recording is available below.
General Information
Background
The COVID-19 Coronavirus Disease was first reported in Wuhan China in December 2019. CDC identifies that it was caused by the virus SARS – CoV-2. Early on, many patients were reported to have a link to a large seafood and live animal market. Later, patients did not have exposure to animal markets which indicates person-to-person transmission. Travel-related exportation of cases into the US was first reported January 21, 2020. For reference the first North American EMS experience of COVID-19 patient transport, including key lessons learned, can be found in the EMS 1 article Transporting Patient 1.
Spread and Identification
Global investigations are now ongoing to better understand the spread. Based on what is known about other coronaviruses, it is presumed to spread primarily through person-to-person contact and may occur when respiratory droplets are produced when an infected person costs or sneezes. Spread could also occur when touching a surface or object that has the virus on it and when touching the mouth, nose, or eyes. Again, research is still ongoing, and advice and guidance will inevitably follow.
For the cases that have been identified so far, those patients with COVID19 have reportedly had mild to severe respiratory illness with symptoms including fever and shortness of breath. Symptoms have typically appeared 2 to 14 days after exposure. Both the WHO and CDC advise that patients that have been to China and develop the symptoms should call their doctors.
COVID-19 Prevention and Treatment
To date, 30 international locations, in addition to the US, have reported confirmed cases of COVID-19 infection. Inside the US, two instances of person-to-person spread of the virus have been detected. In both cases, these occurred after close and prolonged contact with a traveler who had recently returned from Wuhan, China.
The CDC activated its Emergency Operations Center (EOC) on January 21 and is coordinating closely with state and local partners to assist with identifying cases early; conducting case investigations; and learning about the virology, transmission, and clinical spectrum for this disease. The CDC is continuing to develop and refine guidance for multiple audiences, including the first responder and public safety communities.
As at the date of publication there is still no specific antiviral treatment licensed for COVID-19, although the WHO and its affiliates are working to develop this.
The following are recommended preventative measures for COVID-19 and many other respiratory illnesses:
- Wash your hands often with soap and water for at least 20 seconds.
- Use an alcohol-based hand sanitizer with at least 60% if soap and water are not readily available.
- Avoid touching your eyes, nose, and mouth with unwashed hands.
- Avoid contact with people who are sick.
- Stay home when you are sick.
- Cover your cough or sneeze with a tissue, then throw it away.
- Clean and disinfect frequently touched objects and surfaces.
Interim Guidance for EMS and 911
The Centers for Disease Control (CDC) has issued its Interim Guidance for Emergency Medical Services (EMS) Systems and 911 Public Safety Answering Points (PSAPs) for COVID-19 in the United States.
The guidance identifies EMS as vital in responding to and providing emergency treatment for the ill. The nature of our mobile healthcare service delivery presents unique challenges in the working environment. It also identifies that coordination between PSAPs and EMS is critical.
Key points are summarized below:
Recommendations for 911 PSAP Locations
The link between PSAPs and EMS is essential. With the advent of COVID19 there is a need to modify caller queries to question callers and determine the possibility that the call concerns a person who may have signs or symptoms and risk factors for COVID19.
The International Academy of Emergency Dispatch (IAED) recommends that agencies using its Medical Priority Dispatch System (MPDS) should use its Emerging Infectious Disease Surveillance (EIDS) Tool within the Sick Person and Breathing Problem protocols. For those that are not MPDS users, IAED is offering its EIDS surveillance Tool for Coronavirus, SRI, MERS and Ebola-free of charge under a limited use agreement.
Recommended Personal Protective Equipment (PPE)
The CDC recommends that while involved in the direct care of patients the following PPE should be worn:
- Single pair of disposable examination gloves
- Disposable isolation gown
- Respiratory protection (N95 or higher)
- Eye Protection (goggles or disposable face shield)
EMS Transport of a Patient Under Investigation (PUI) or Patient with Confirmed COVID19
- Notify receiving healthcare facility so appropriate precautions can be put in place
- Discourage family and contacts from riding in transport vehicle
- Isolate the vehicle driver from the patient compartment by closing the windows between compartments and ensuring that the vehicle ventilation system is set to the non-recirculated mode
- Document patient care
Cleaning EMS Transport Vehicles After Transporting PUI or Patient
- Don PPE for cleaning with disposable gown and gloves, facemask, and goggles or face shield if splashes are anticipated
- Routine cleaning and infection procedures should follow organizational standard operating procedures
- Use protect use products with EPA-approved emergent viral pathogens claims
Once transport is complete, organizations should notify state or local public health authorities for follow up. Additionally agencies should (if not done already) develop policies for assessing exposure risk and management of EMS personnel, report any potential exposure to the chain of command, and watch for fever or respiratory symptoms amongst staff.
Employers Responsibilities
While not specific to COVID-19, agencies should:
- Assess current practices and policies for infection control
- Job- or task-specific education and training
- PPE training and supply
- Decontamination processes and supplies
Local EMS Considerations
- PPE supplies
- 911 and EMD call taking activities
- Appropriate approach to potential patients
- Educational resources for EMS personnel
- Interaction with local public health/healthcare systems/emergency management
- Interaction with local fire and law enforcement
- Considerations for local jails
Further Reading
- World Health Organization (WHO)—For a wider perspective, the WHO provides both a daily live online briefing and written situation report.
- FirstWatch—FirstWatch Solutions maintains a Health Intelligence site that is available for all to use. The site is not limited to COVID19 but is a useful reference to emerging health trends. Additionally, FirstWatch, in partnership with the Paramedic Chiefs of Canada, is presenting regular webinars on COVID-19 which can be located via the Health Intelligence web page.
- Updated information about COVID19
- Infection prevention and control recommendations
- Additional information for healthcare personnel
- CDC’s case definition for a person under investigation (PUI) for COVID19
- CDC Quarantine Station Contact List
- Guideline for Isolation Precautions: Preventing Transmission of Infectious Agents in Healthcare Settings (2007)
- Exposure risk and management
- Infectious Disease Playbook
Conclusion
The COVID19 situation constantly evolving. Agencies should defer to their local EMS authorities, Public Health departments, and the CDC for definitive guidance. Going forward, the AAA will continue to both monitor the disease and alert issues to the membership.
Non-Emergency Transport: Avoiding the Fraud Trap [Sponsored]
By Eric van Doesburg, MP Cloud Technologies
This sponsored post is not endorsed by the American Ambulance Association. It reflects the views of the author.
Did you know that one of the most common practices in our industry could put your company at financial risk? Transporting patients not qualified for ambulance transportation is a hot topic these days as it has heavily contributed to the rise of Medicare fraud cases. This issue has grown even more relevant recently with a case in Florida, where not only was the EMS company found liable of fraud, but it was the first time several hospitals were held culpable as well.¹
While the burden of proof falls on the government to satisfy the statutes in the Federal False Claims Act, the fact is investigators are becoming more aggressive in fighting these types of billing schemes.
“The fact is investigators are becoming more aggressive in fighting these types of billing schemes.”
Yes, there are some bad actors in our industry like any other, but more times than not employees simply may be unaware of the qualifications needed when dispatching non-emergency transport.
Thankfully, a company can protect its financial future simply by having the necessary protocols in place.
For ambulance transportation to be covered by Medicare for a patient, the answer must be “yes” to at least one of the three criteria listed below:
- “Is the patient bed-confined?”
- “Does the patient require assistance to get out of bed?”
- “Is the patient unable to safely sit in a wheelchair for the duration of the transport?”
Dispatchers must ask these specific questions in order to understand the scope of the situation – a step that should be incorporated into your business’ procedures immediately. If it is determined that the patient meets none of the above criteria, then an alternative transportation source must be sought and you have a couple of options.
Non-EMS Transport Options
Rideshare Partnership
Uber™ and Lyft™ have not only affected how we approach transportation as a society but have left a prominent mark on the EMS industry as well. According to a University of Kansas study, the use of ambulance transportation dropped 7% in cities that adopted ride-sharing platforms.² Consider the formation of a partnership with these companies as a low-cost alternative for non-emergency transport that could reduce your liability and develop a sustainable revenue stream for the future without a lot of overhead. Of course, just because the patient may not meet the Medicare criteria for non-emergency transport doesn’t mean that they are in a condition to be able to ride in a car by themselves. This is where the situation can become a little tricky. Is Uber™ or Lyft™ really the bestoption for an elderly person who may have some mild form of dementia and is being released after having a medical episode?
Add Non-Emergency Fleet
As an alternative, another option would be setting up your own fleet of non-emergency transport to cater to your clients’ specific needs. These non-emergency shuttles can ensure a consistent and legal discharge process to keep you in compliance and managing dispatch on your terms. It also allows for a higher level of patient care during the transport than a ride-sharing service can provide.
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With the stakes for fraudulent claims getting higher, you’ll want to make sure you have a protocol in place that protects your business, employees, and clients from any hint of impropriety. However, with the right planning and core systems/partnerships, it will make the process for handling non-emergency transport that much easier… and possibly lead to new revenue channels not available in the past. That’s something we can all get excited about.
¹https://www.modernhealthcare.com/article/20150511/NEWS/150519994
HHS OIG Issues Advisory Opinion on Community Paramedicine
HHS OIG Issues Advisory Opinion Permitting Community Paramedicine Program Designed to Limit Hospital Readmissions
On March 6, 2019, the HHS Office of the Inspector General (OIG) posted OIG Advisory Opinion 19-03. The opinion related to free, in-home follow-up care offered by a hospital to eligible patients for the purpose of reducing hospital admissions or readmissions.
The Requestor was a nonprofit medical center that provides a range of inpatient and outpatient hospital services. The Requestor and an affiliated health care clinic are both part of an integrated health system that operates in three states. The Requestor had previously developed a program to provide free, in-home follow-up care to certain patients with congestive heart failure (CHF) that it has certified to be at higher risk of admission or readmission to a hospital. The Requestor was proposing to expand the program to also include certain patients with chronic obstructive pulmonary disease (COPD). According to the Requestor, the purpose of both its existing program and its proposed expansion was to increase patient compliance with discharge plans, improve patient health, and reduce hospital inpatient admissions and readmissions.
Under the existing program, clinical nurses screen patients to determine if they meet certain eligibility criteria. These include the requirement that the patient have CHF and either: (1) be currently admitted as an inpatient at Requestor’s hospital or (2) be a patient of Requestor’s outpatient cardiology department, and who had been admitted as an inpatient at Requestor’s hospital within the previously 30 days. The clinical nurses would identify those patients at higher risk of hospital admission based on a widely used risk assessment tool. The clinical nurses would also determine whether the patient had arranged to receive follow-up care with Requestor’s outpatient CHF center. Patients that do not intend to seek follow-up care with the CHF center, or who have indicated that they intend to seek follow-up care with another health care provider, would not be informed of the current program. Eligible patients would be informed of the current program, and offered the opportunity to participate. The eligibility criteria for the expanded program for COPD patients would operate in a similar manner.
Eligible patients that elect to participate in the current program or the expanded program would receive in-home follow up care for a thirty (30) day period following enrollment. This follow up care would consist of two visits every week from a community paramedic employed by the Requestor. As part of this in-home care, the community paramedic would provide some or all of the following services:
- A review of the patient’s medications;
- An assessment of the patient’s need for follow-up appointments;
- The monitoring of the patient’s compliance with their discharge plan of care and/or disease management;
- A home safety inspection; and/or
- A physical assessment, which could include checking the patient’s pulse and blood pressure, listening to the patient’s lungs and heart, checking the patient’s cardiac function using an electrocardiogram, checking wounds, drawing blood and running blood tests, and/or administering medications.
The community paramedic would use a clinical protocol to deliver interventions and to assess whether a referral for follow-up care is necessary. To the extent the patient requires care that falls outside the community paramedic’s scope of practice, the community paramedic would direct the patient to follow up with his or her physician. For urgent, but non-life threatening conditions, the community paramedic would initiate contact with the patient’s physician.
The Requestor certified that the community paramedics would be employed by the Requestor on either full-time or part-time basis, and that all costs associated with the community paramedic would be borne by the Requestor or its affiliates. The Requestor further certified that no one involved in the operation of the program would be compensated based on the number of patient’s that enroll in the programs. While one of the states in which the Requestor operates does reimburse for community paramedicine services, Requestor certified that it does not bill Medicaid for services provided under the program.
The question posed to the OIG was whether any aspect of the program violated either the federal anti-kickback statute or the prohibition against the offering of unlawful inducements to beneficiaries.
In analyzing the program, the OIG first determined that the services being offered under the program offer significant benefit to enrolled patients. The OIG specifically cited the fact that one state’s Medicaid program reimbursed for similar services as evidence of this value proposition. For this reason, the OIG concluded that the services constitute “remuneration” to patients. The OIG further concluded that this remuneration could potentially influence a patient’s decision on whether to select Requestor or its affiliates for the provision of federally reimbursable items and services. Therefore, the OIG concluded that the program implicated both the anti-kickback statute and the beneficiary inducement prohibition.
The OIG then analyzed whether the program would qualify for an exception under the so-called “Promoting Access to Care Exception.” This exception applies to remuneration that improves a beneficiary’s ability to access items and services covered by federal health care programs and which otherwise pose a low risk of harm. The OIG determined that while some aspects of the program would likely fall within this exception, other aspects would not. Specifically, the OIG cited the home safety assessment as not materially improving a beneficiary’s access to care.
Having concluded that there was no specific exception that would permit the arrangement, the OIG then analyzed the arrangement under its discretionary authority, ultimately concluding that the program posed little risk of fraud or abuse. In reaching this conclusion, the OIG cited several factors:
- The OIG felt that the potential benefits of the program outweighed the potential risks of an improper inducement to beneficiaries. The OIG cited the fact that beneficiaries must have already selected Requestor or its associated clinic as their provider of services before learning about the program. As the OIG indicated “the risk that the remuneration will induce patients to choose Requestor or the Clinic for CHF- or COPD-related services is negligible because patients already have made this selection.” The OIG also noted that the community paramedic will inform beneficiaries of their right to choose a different provider prior to referring the beneficiary to the Requestor or its clinic for services outside the scope of the program.
- The OIG noted that, to the extent the program works as intended, it would be unlikely to lead to increased costs to federal health care programs. As noted above, Requestor had certified that it would not bill federal health care programs for the services of the community paramedic.
- The program was designed in a way as to minimize the potential for interference with clinical decision-making.
- The Requestor certified that it would not advertise or market the program to the public, thereby minimizing the chances of beneficiaries learning about the program prior to selecting Requestor for their CHF- or COPD-related care.
- The OIG noted that the program appeared to be reasonably tailored to accomplish the goal of reducing future hospital admissions. For example, the OIG cited the fact that the Requestor limited inclusion in the program to patients deemed to be at a higher-than-normal risk of hospital admission or readmission, and that it made these determinations using a widely used risk assessment tool. The OIG noted that these patients would likely benefit from the continuity of care offered under the program. In addition, the OIG noted that the community paramedics would be in a position to keep the patients’ physicians appraised of their health by documenting all of their activities.
Potential Impact on Mobile Integrated Health and/or Community Paramedicine Programs
OIG advisory opinions are issued directly to the requestor of the opinion. The OIG makes a point of noting that these opinions cannot be relied upon by any other entity or individual. Legal technicalities aside, the OIG’s opinion is extremely helpful to the industry, as it lays out the factors the OIG would consider in analyzing similar arrangements. Thus, the opinion is extremely valuable to ambulance providers and suppliers that current operate, or are considering the operation of, similar mobile integrated health and/or community paramedicine programs.
Recovering Loss of Revenue from “not at fault” Accidents
When your units get hit by a third party and the vehicle is out of service, are you getting Loss of Revenue for the downtime while the unit is being repaired? Whether you answered yes or no to that question, reading this article will be the one of the most lucrative uses of your time this year.
A call comes in and your dispatcher does a perfect job of answering and scheduling the run. The EMT’s jump into the clean, fueled, and well stocked ambulance responding to the call. Then from out of nowhere, a car turns directly into the ambulance’s path rolling through a stop sign. Now what? You have two paramedics stranded on the side of the road who will be spending the next few hours on paperwork and drug testing. In addition, all the drugs and small equipment need to be removed or secured. Hopefully you have another unit to dispatch or your competitor may have already been called.
What happens next is key to getting maximum recovery for your losses caused by the accident.
Key items that help maximize your recovery from accidents:
- Educate and equip fleet drivers with the tools necessary to collect key accident information at the scene and relay it. This includes a description of the accident, clear color pictures of the accident scene, the damaged vehicles, and third-party driver’s license and insurance information.
- Gather as many witnesses as possible and statements from both drivers.
- On board videos are great, but if not, having a smart phone video of the damage and intersection can be very helpful if the liability is in question.
- Get an accurate and thorough estimate. Be aware that, for the most part, insurance companies are motivated to pay out the least amount possible to get the claim settled. Their adjusters are typically not trained accurately determine the damage to specialty vehicles or the equipment they may contain. Using a TPA with strong experience with commercial fleets is critical.
We are surprised how many firms don’t realize or understand what they are entitled to recover because of an accident where their driver was not at fault. Essentially, the law supports that the owner is entitled to the use of their “chattel” and compensation pursuant to the same. Here is an interesting titbit. Chattel is originally a Latin and old French term referring to moveable personal property. A good term to throw out at the next risk managers meeting to impress everyone. With that said, what you are entitled to and what shows up in your mailbox are two drastically different things. Insurance companies are motivated to pay the least amount possible and delay that payment as long as possible.
Most people assume that insurance companies make money when they generate more in premiums than they pay out in losses and expenses, but for the most part that’s not true. Most insurers are happy to break even on their underwriting and make their money by investing the premiums and keeping the investment returns.
What am I entitled to from a “not at fault” accident? There are a lot of factors influencing this, but essentially you are entitled to your physical damage, diminution of value, and loss of use/revenue. How much you are entitled to are the subjective negotiations that firms like ours engage in hundreds of times each day. Driver liability, statute of limitations and minimum policy limits vary from state to state. Typically, the state where the accident happens will be the applicable laws and regulations.
If I have a spare unit to take the place of the damaged vehicle, am I still entitled to Loss of Revenue? The short answer is yes, but getting the carrier to ink the check is another matter. There are real costs of having a spare unit which is why the law supports the loss of the use as a recoverable item. Acquisition cost, maintenance, licensing, certification, insurance, and storage are all costs incurred by having a spare unit.
Pursuing Loss Recovery
The following are steps fleets can take to help maximize recovery:
- Pursue all possible recoveries. There is often potential recovery from the third-party drivers in the form of an umbrella policy, company policy, or personal assets. Driver liability, statute of limitations and minimum policy limits vary from state to state. The key is to know which accidents offer what potential in which states, and then to pursue recovery using the latest industry tools as quickly as possible.
- Follow insurance industry documentation standards. The required forms need to be properly completed and submitted to the third-party driver’s insurance carrier. Knowing insurance industry regulations, standards, and the law are key to move the carriers to action. Technically, a carrier can wait 30 days after receiving a demand before taking action on the claim.
- A key component to Loss of Revenue is accurate records showing the income the unit generated prior to the accident. This is the hardest to recover and gets the most pushback from the insurance companies. Putting the data in a format that meets the insurance company’s needs varies by company.
- Even after the carrier has agreed to pay, be prepared to make a lot of follow-up calls and emails to get your claim paid. A common tactic used by carriers is to drag out the claim hoping you will either give up or accept less. Essentially wearing you down.
The second key recovery component is Diminution of Value (DV), or Loss of Market Value the vehicle suffers even after it is repaired. Age of the vehicle, miles, condition, and other factors determine this amount. Without a strong recovery plan or Third Party Administrator (TPA), we see significant diminution of value left on the table. The key here is strong data which supports your valuation utilizing use multiple sources and have extensive experience and a successful track record for recovering DV.
Getting accurate value when a vehicle is a total loss. The term “Total Loss” is an insurance term lacking legal definition. Carriers have often used title branding laws to determine if a vehicle is a “Total Loss”. While each state has different criteria for “branding” titles, vehicles can, and have been, paid as total losses with damage percentages well below the title branding statutes. Carriers often tout statements such as “Federal Guidelines” or “State Statutes” when attempting to settle claims. More accurately, legal entitlements are based upon what is called the Restatement of Torts, and defined by case law in each state. Typically, property and casualty insurance adjusters don’t understand these laws and again are motived to pay out the minimum possible. Engaging a firm that specializes in commercial fleet claims can provide an arm’s length transaction necessary to be pro-active on the front side in setting the claim up properly, which usually results in a higher recovery.
So how do you win at the recovery game? Well unfortunately you are in a game where the opponent is highly motivated to not pay or pay the least possible, has their own set of rules on how much you should get, and make most of their profit on dragging out a payment when they finally do decide to pay.
There are essentially three routes you can pursue.
- Handle the claims yourself. Unless you have extensive knowledge in the law and insurance industry, plus have ample time to talk to the voicemails of insurance carriers, this option may not be ideal.
- Let your insurance company handle the claim. They will pay your Physical Damage, but rarely does the policy have coverage for Loss of Revenue and Diminution of Value.
- Hire a TPA (Third Party Administer) to handle the claims for you. Select a firm with a long track record, experience with specialty vehicles, adequate technology, a strong legal department, and specializes in Loss of Revenue recovery. Make sure their fees are performance based and they only win if you do. They can recover Loss of Revenue, Diminution of Value (inherent and repair related) and other costs typically not recovered.
Few fleets have the number of trained personnel in each of these areas to adopt these best practices. If the fleet’s resources are already stretched to capacity, consider outsourcing to a TPA. The chances are the partnership will yield state-of-the-art best practices and more than pay for itself.
I hope you found this article helpful, don’t hesitate to contact me with any questions or to learn more.
Brian J. Ludlow is Executive Vice President for Alternative Claims Management. He is an entrepreneur and consultant to the insurance, financial, and transportation industries. Brian specializes in disruptive technologies. His firm has transformed the accident claims recovery process.
bludlow@AltClaim.com | 231-330-0515
Family Liaisons Following EMS Line of Duty Deaths
I was just a kid when I started in EMS. 23 years old, hungry for adventure, and ready for everything the world of EMS was prepared to give me. Car accidents, gunshot wounds, stabbings, intoxicated shenanigans, elderly falls, fist fights, medical emergencies, strokes, and cardiac arrest were all on my list of expected possibilities. One of the scenarios I had not thought of, and nobody presented to me throughout school and orientation, was the possibility of clocking in for shift and not going home. I do not recall line of duty deaths being a discussion point in the paramedic curriculum, job interview, or orientation process. I had experienced the unexpected loss of a younger sibling due to a motor vehicle crash before I started my journey in EMS, but the fact that life is short and unpredictable did not connect with the fact that I was knowingly and willingly walking myself into unknown and potentially dangerous situations with each response. Even after the UW Med Flight crash happened early in my career, and in my service area, we simply did not talk about our own potential for death as a direct result of our profession.
Years later, after many more line of duty deaths and even more reports of violence against EMS and healthcare workers, this topic weighs heavy on my mind. In my time as Staff Development Manager for a service, I pushed for the DT4EMS courses to train our medics on how to recognize potential dangers, escape those situations, and defend themselves if they are unable to escape. We all know the ‘scene safe/BSI’ tagline and list of what things might make a scene unsafe is not enough. As the Rescue Task Force (RTF) formed, I watched as some were excited for the opportunity to be involved and others started to question their willingness to respond to so many unknown situations as their young families were beginning to grow. I started asking myself if EMS agencies are doing enough in terms of preparing themselves and their employees for the possibility of a line of duty death.
The Line of Duty Death Handbook, published in part by the AAA, is a great tool to start building policies, protocols and personnel records. The handbook guides you through the importance of having employees fill out emergency contact and next of kin forms, and keeping them updated, as well as assigning family liaisons and how to manage coverage for funeral services. As I reviewed this, I started thinking about the assignment of a family liaison—a member of your agency who knew the individual well and will be the primary contact for everything the family needs once the notification has been made. What type of person should be assigned this role, and what kind of training should they have? I sat down with KC Schuler, MDiv and board member for the Fox Valley Critical Incident Stress Management group to discuss.
What are some considerations services should make when putting together their line of duty death policy/procedure?
I think the first significant consideration should be conducting pre-incident training. I mean, are you starting the conversation about critical incident stress exposure all the way up to, and including, the possibility that they may never go home to their family, at orientation? During onboarding? So many of the EMTs and Paramedics coming in are young, and this may be their first job. In my experience, they can be somewhat blind to the possibilities. Early education and creating a culture of support—including letting them know you have their back (and their family’s back) in every potential scenario is important. The second consideration, I think, is to determine what scope you define as a line of duty death. The on-shift motor vehicle crash or incident resulting in death while on the clock is apparent, but what about suicide? If someone is having significant job-related stress and commits suicide, will that be looked at as a line of duty death, or not? This is something all organizations need to consider before such an event happens.
S: What type of actions would you recommend take place, or are discussed, as part of the orientation process?
KC: This is a great time for employees to fill out the emergency contact and next of kin form—this also provides an opening to discuss the possibility of death and the importance of filling out the form accurately and keeping it up to date. They are the best ones to tell you who you should notify in such a situation; guessing in the event of a death is not ideal. A portion of orientation and annual training should also be spent on mental health, including awareness, recognition of post-traumatic stress symptoms in themselves and their peers, and available support resources. Trained peer support and EAP can be very valuable in the management of work and home related stressors. Again, being intentional to build and sustain an organizational culture of support prior to an unfortunate tragedy like a line of duty death will help all those involved.
S: The Line of Duty Death Handbook talks about assigning a family liaison—a person who becomes the 24/7 primary contact for the family once notification has been made. This person should be available, in person and via phone, and dedicated to the family whether it is household chores such as mowing the lawn and grocery shopping, to communicating with out of town family members and arranging hotels. Who should be considered for such an assignment, and what might the service do to prepare these individuals?
KC: This is a high-intensity assignment, and this role should not be assigned to shifts in the beginning either. Being a family liaison is a big responsibility, and it is not a responsibility that should shift from person to person; ideally, the family will have one liaison for the duration. Trust is a significant factor—the family must trust the individual they are assigned, so that individual must be able to build that trust or recognize early if it is not a good match. Services should consider the following in their selection of a family liaison:
- Someone who is specially trained in being a family liaison. The nature of this position is demanding and can significantly interfere with the liaison’s personal life and responsibilities of emotionally supporting another. They need to be able to have clear boundaries, open lines of communication to leadership, and have a stellar support system in place as well. The International Critical Incident Stress Foundation does offer a 2-day LODD course.
- Preferably, the family liaison would not have any other roles (such as being an honor guard member) as they will likely have other duties and responsibilities throughout the process and at the funeral itself. The liaison duties need to be 100% dedicated to the family.
- Gender sensitivity—If the deceased is a male, you may want to assign a female liaison to the spouse as there can be a lot of strong emotions during this time and unhealthy attachments can form. You should consider gender identity and sexual preference in assigning a liaison as well.
Training and preparation of individuals for family liaison assignment should happen before an event like this ever occurs.
S: If I am a service director looking to send a few people to train for this, what type of people should I look for?
KC: If I had to provide a list of characteristics for liaison selection, it would probably include someone who:
- Does not gossip and respects confidentiality.
- Can make things happen—someone who is comfortable making, and either has the authority to make decisions on behalf of the service, or has direct contact with someone who can.
- Has a great support system of their own.
- Understands and respects boundaries—can set limits where appropriate and necessary.
- Is comfortable speaking, but also understands and can recognize the importance of silence, or when not to respond.
S: When it comes to families, there are a lot of dynamics a liaison might have to contend with such as divided families or family members that do not get along. If more than one individual is involved in a LODD, such as two members killed in a car accident, there may also be dynamics between those two families that need to be considered. What are your recommendations for addressing those type situations, where either a single family or multiple families may be at odds?
KC: If there is more than one family involved (i.e., two employees) you will want to assign each family a liaison, and those liaisons will need to be in close communication with each other and the organization leadership. One thing agencies may wish to consider is holding family support or family networking events throughout the year, before an event like this happens. I mean, beyond the Christmas parties and summer picnics where all families are invited—events that allow family members of your employees to get together, build relationships, and form a support system between families who understand the dynamic of supporting someone in EMS. If families are meeting for the first time as the result of a fatal accident, the dynamic will likely be much different (and more difficult) than if they are afforded a place to get to know each other and form bonds before such an event would happen. It is a lot easier to blame a stranger than a friend; it is easier to share pain and experience with someone you share a bond.
If there is pre-incident conflict within a family, such as animosity between divorced parents or an ex-spouse, these situations become more difficult to manage. Training will help the liaison better navigate and handle these situations.
S: You mentioned before, the importance of knowing the resources in your area—what would you say to those services who might plan to reach out to their local CISM or hospital for a family liaison or other support in this situation?
KC: As I mentioned before, EAP is a valuable resource but likely not the best as a stand-alone support in the event of LODD, and it certainly would not be able to function as a family liaison. Many hospitals may have pastoral care staff, such as myself; however, many would not have the capacity to operate as a family liaison or the awareness, authority, and connections to make decisions on behalf of your service. So, neither of these options would not be the best plan in my opinion. CISM teams can help in debriefings, but again, that is different than functioning as a family liaison. Some of your staff members that are trained as CISM peer counselors, however, may be excellent candidates for continued training in LODD and more specifically, as family liaisons.
S: You also mentioned how the family liaison should be taken off shift responsibility and assignments while they are functioning as the family liaison. What time frame should a service expect, and could the director or administrative staff function as the liaison to reduce scheduling disruptions?
KC: The time frame will be variable and unique to each situation; this is part of the importance of a service’s selection and training of these individuals. They need to determine when the family needs the high-intensity liaison, when to move to periodic support, and when to transition out to periodic or then eventual annual check-ins. They need to do this without creating a co-dependence.
A director or administrative staff would not be the ideal candidate for the family liaison assignment. The director will be busy dealing with many other operational details and would not be able to devote the time or attention to the family during the high-intensity phase. Ideally, the liaison will be someone the fallen individual knew, worked alongside, and had a good relationship with; someone who can share some stories with the family. The liaison’s ability to do this goes back to the importance of fostering the family/spousal support network as well.
There are many ways in which services can prepare for a line of duty death. Option one is to bury your head in the sand and pretend it will never happen to you. This, we know, is a lie; a lie to ourselves, our employees and their families. Option two is to address the potential with eyes wide open and full support starting in orientation and stretching through the selection of qualified employees for advanced training. Even if I am lucky enough never to experience a LODD personally, I would rather work for an organization adopting option two every time.
“It is a curious thing, the death of a loved one. We all know that our time in this world is limited and that eventually all of us will end up underneath some sheet, never to wake up. And yet it is always a surprise when it happens to someone we know. It is like walking up the stairs to your bedroom in the dark, and thinking there is one more stair than there is. Your foot falls down, through the air, and there is a sickly moment of dark surprise as you try and readjust the way you thought of things.”
― Lemony Snicket, Horseradish
HIPAA and Mobile Devices: What Your Service Needs to Know
For ambulance services, HIPAA compliance is a particularly sensitive issue. Because of the sensitive nature of the health data that EMS and EMT professionals deal with on a daily basis, HIPAA Privacy and Security standards must be carefully adhered to.
This issue becomes even more sensitive when you consider that most of the data collected during pre-hospital care will likely be collected, tracked, and documented on a mobile device. Laptops, smartphones, and tablets are indispensable tools for ambulance care. Most of these devices will have access to electronic health records (EHR) platforms, which will in turn be connected to the rest of a hospital’s EHR data.
While mobile devices can provide convenience in life-or-death situations, they are also particularly vulnerable to the risk of a data breach. A data breach of unsecured health information can lead to serious HIPAA violations and put patient privacy at risk.
The kind of health information that these devices have access to is called protected health information, or PHI. PHI is any demographic information that can be used to identify a patient. Common examples of PHI include names, dates of birth, medical information, insurance ID numbers, addresses, full facial photos, and telephone numbers, to name a few.
The HIPAA Rules set specific standards for maintaining the privacy, security, and integrity of PHI. Though the regulation can seem complex, the standards are in place to safeguard PHI. As per HIPAA, ambulance services necessarily fall under the category of Covered Entities, meaning that they are responsible for maintaining compliance with both the HIPAA Privacy Rule and the HIPAA Security Rule.
These two rules set limits for how and when PHI must be stored and accessed. Below, we list a few of the major components of the HIPAA Rules that all ambulance services can implement in order to keep PHI safe and secure on the go.
- All mobile devices that can access PHI must have full-disc encryption. Additionally, all devices should be routinely backed-up on encrypted servers. In the event that a device is lost or stolen, full-disc encryption will keep hackers or thieves from accessing sensitive health data.
- Your organization should have HIPAA policies and procedures in place pertaining to mobile devices taken “off-site.” This would necessarily include all laptops, tablets, and smartphones with access to PHI that are used in pre-hospital care in an ambulance. By outlining when devices are permitted to be used, who is permitted to use them, and how they are to be handled in off-site settings, your organization will mitigate the risk to PHI stored on these devices.
- Keep a full inventory of all devices within your organization that can access or handle PHI in any way. Routine check-ups on the condition and location of devices listed in your inventory will help ensure that devices are not misplaced. And in the event that a device is misplaced or stolen, organization officials will notice as soon as the inventory is reviewed so that action can be taken to remedy the breach.
- Access to PHI on mobile devices and in pre-hospital settings should be limited only to essential members of the organization’s workforce. This is known as the Minimum Necessary Standard. It’s a part of the HIPAA Privacy Rule that states that access to PHI must be limited based on employees’ roles, and that when access is granted, it should be limited to the minimum access necessary for each employee to perform their role.
These are just a few of the ways that ambulance services can protect PHI and comply with HIPAA mobile device standards.
In addition to the actions listed above, a total compliance program that addresses the full extent of the law must be in place in order to prevent HIPAA violations and data breaches.
Addressing HIPAA compliance can help ambulance services confidently treat their patients without worrying about the risk of data breaches or government fines.
What I Wish I Had Known
Congratulations! You were selected for the Paramedic Supervisor position, if you accept, we’ll start the transition immediately.
I remember the excitement I had when I heard those words so many years ago. The excitement that carried strongly through 2 days of celebrating with my husband, anticipating the new world I was about to be part of; making a mental list of all the mountains I couldn’t wait to move! This excitement was quickly drowned by a sinking feeling deep in my gut. It felt like running out of gas on a country highway at one in the morning and your cell phone is dead; it’s dark, there is nobody around, and you cannot phone a friend.
Whether it comes right away, or later—because of the reaction of people we thought were friends or feeling overwhelmed in a new situation you were expected to handle with precision, we’ve all felt that feeling as a new leader. By sharing our stories with one another, the success and the failures, we all grow.
I remember getting so much advice from those who walked the road before me, some solicited some not. The stories were sometimes shocking, often comical and always gave me perspective and insight into my own blunders – most importantly the stories many shared with me taught me the importance of humility and the ability to laugh at myself, admit my mistakes, learn and move on. At some point, the tide started turning, and friends and colleagues began asking me for my stories and advice. Although I often felt like I wasn’t experienced (i.e. old enough) to be offering any advice I realized it’s not necessarily the age or years of experience behind the story that makes it meaningful. The power is in the ability to share an experience through storytelling—finding common ground amongst the hierarchy of titles and job descriptions.
I think it is easy to lose sight of how our words and actions can affect others as we are wrapped up in our day to day and moving down the checklist of tasks. The influence of a leader in an organization, even an informal leader, is long lasting and not to be taken for granted. Over the past year, I’ve been talking to many EMS leaders of the past and present. I’ve been asking them what they wish they would have known when they first started their leadership journey, and what advice they might give to others just starting out. Here are 10 of the most common answers I received.
Top 10 Things I Wish I Had Known
- I wish I would have known I could be myself. Being myself earned me the role, but suddenly it didn’t seem like enough. At first, I thought others were putting all this pressure on me to be an amazing supervisor immediately – in hindsight, I realize I was putting the pressure on myself and it was totally unnecessary. Being myself allowed me to be a more effective supervisor for my team and I wish it hadn’t taken me so long to figure it out.
- I wish I would have learned earlier how important listening is. Listening to understand your people, listening to learn and listening to understand the politics that are happening beyond the surface.
- I wish I would have known that I didn’t have to be right all the time; I wasn’t expected to be right all the time. I was only expected to be an honest and reliable resource for my team.
- Change is slow. PAINFULLY slow. In EMS there is constant instant gratification – you see a problem with a patient, you fix it, you drop them off. Transitioning to an administrative role and learning that change is slow and takes time (SO MUCH TIME!) is more difficult than I ever would have imagined. I had to really learn to see the long game.
- It’s not a “day job”. As a leader, you’re never off duty. Whether you’re on a regular rotation as a shift supervisor, or in the office as a manager or director, EMS is a 24/7 world which means you work nights, weekends and holidays right along with your team. You may not be on a truck or at a station—but you’re still available to them all the time.
- I wish I would have understood how important mission, vision, and values really are to a company, and how important it is to talk about them with staff.
- We’re all learning, and it is OK to ask for help.
- Just because a staff member is asking me a question, it does not mean they are challenging my authority. As a leader, it took me a long time to realize that I should embrace a staff member challenging a decision so long as they are doing it in a constructive manner.
- I wish I would have known how much of an impact I have on people. I don’t mean that in an arrogant way. I’ve had staff bring up conversations we had years ago, and I had forgotten all about it—but they were still carrying that encounter with them.
- That it wasn’t for me. I thought I wanted to be a supervisor – a leader. I was wrong. I was unhappy with the role and everyone knew it but me, and I was becoming destructive.
When I came to the realization that I wasn’t the right person for the role, my boss allowed me a front row seat to the best example of leadership I have personally witnessed. He allowed me to step back from the role but didn’t forget about me; he continued to invest in me as an employee and as an individual despite the certain protest of others. To this day, he continues to provide guidance on my professional endeavors and is someone I truly look to for honest advice.
Ransomware: A Ticking Time Bomb for Health Care
By Cindy Elbert
President, Cindy Elbert Insurance Services, Inc
If you’re doing business online, you need cyber-insurance. This fact was never made truer than on May 12, 2017 when 50,000 businesses in at least 74 countries were hit by a ransomware attack code named “WannaCry”. Hackers demanded companies to pay a $300 ransom fee or their files would be published on the Internet. The data thieves targeted mostly hospitals and other medical facilities because their data not only included names, home addresses, addiction histories, financial information and religious affiliations but also disclosed patients’ mental health and medical diagnoses, HIV statuses and sexual assault and domestic violence reports. A gold mine of personal information for those with dark purposes.
Two days earlier, a data breach at the Bronx Lebanon Hospital Center in New York compromised the medical records of at least 7,000 people. According to NBC News, “Leaks from the Rsync servers, which transfer and synchronize files across systems, are common. How many more nude photos of patients or ultrasound images will be exposed because of misconfigured Rsync backups?”
On May 4, 2017, a group calling themselves TheDarkOverload uploaded almost 180,000 stolen patient/medical records from three companies onto the Internet because they refused to pay a ransom. The databases stolen were in the .csv format and contained health information about cardiac diagnoses and psychiatric conditions such as depression, along with date of birth and social security numbers.
Most ransomware attacks are led by organized criminal groups utilizing a network of computers infected with malware that then poisons other computers once a spam message is opened. An example of a spam malware would be emails falsely marked as being from a co-worker or friend asking a recipient to open an attached file. Or, an email might come from a trusted institution, like a bank or merchant, asking you to perform a specific task. In other instances, hackers will use scare tactics such as claiming that a victim’s computer has been used for illegal activities to bully victims. When the malware is executed, it encrypts files and demands a ransom to unlock them.
Imagine the nightmare scenario of medical teams out on the field relying on electronic devices such as tablets, laptops, smartphones and PDAs to access patient care records suddenly discovering that their data has been locked, captured by malicious malware., held for ransom with lives in the balance.
Companies need the protection cyber liability insurance offers now more than ever.
Why Your Company Needs Cyber Liability Insurance
- A single data breach could cost your company thousands of dollars, not to mention the hit to your reputation.
- Hackers can be halfway across the world—or at the desk next to you.
- An employee losing a company laptop or cell phone could result in a major security breach.
- The more personal information your company collects opens your exposure to the likelihood of a data breach attack.
- As of March 28, 2017, Internet providers can collect and sell your web browser history opening more opportunities for data to be stolen.
- The average forensic investigation runs $25,000 per server.
Cyberthreats By the Numbers
- Sixty percent of uninsured small businesses close their doors within six months following a cyber attack.
- According to the 2016 NetDiligence Cyber Claims study, Healthcare data breaches made up 19% of all breach sectors.
- The average cost for a breached healthcare company is $717,000.
- According to the Identity Theft Resource Center’s 2017 Data Breach report, almost 2 million records have been stolen so far this year, making up 22 percent of all breaches – and this is before the “WannaCry” ransomware attack.
- Forty-seven states mandate that your company take certain measures in the event of a security breach
Protect Your Company
Ransomware attacks and cyber theft will not be defeated any time soon. So now is the time to ask: How do you store sensitive information? How do you control access to sensitive information? Do you utilize a firewall and protection software? Do you allow employees and others remote access to your data bases? Do you have a written security policy? And, most importantly, do you have cyber liability insurance? Is it safe? If your company stores customer information, especially billing and medical data, then there is no question about it: You must protect yourself from the growing legion of cyber predators. You need cyber liability insurance.
About the Author
Cindy Elbert is President of Cindy Elbert Insurance Services, Inc. She is a licensed Property & Casualty Insurance broker/agent, and a proud member of the American Ambulance Association, California Ambulance Association, Arizona Ambulance Association, and The Independent Agents Association.
Cindy has been assisting ambulance providers with their insurance needs since 1982. She understands your questions and concerns and with her relationships with insurance underwriters she can provide you with coverage and service you deserve.
www.ambulanceinsurance.com
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Time to Automate
Founded in 1964, now nationally recognized, Mohawk Ambulance Service is the largest privately owned ambulance service in upstate New York. Our organization services six emergency centers, makes 56,000 trips annually and employs a team of more than 250 staff members. Eighty percent of our trips are for emergency transports where patients are unknown, in critical condition or have no identifying information. Finding fast, efficient ways to verify demographics and discover insurance coverage for these patients is imperative for our revenue cycle and our bottom line.
We’ve always worked closely with our local hospitals and nursing homes to obtain information. Many standard processes have been refined over the years with checks and balances to verify coverage, screen deductibles and reduce eligibility-related rejections before claims are submitted to a payor. But our billing team knew we could do more to eliminate duplicate data entry and processing lag time.
This article describes our journey to a more streamlined billing process. It includes lessons learned and best-practice recommendations for other EMS providers looking to improve staff efficiency and reduce receivables.
First Stop: Real-Time Insurance Discovery
The first area we tackled was insurance discovery where we had three employees stationed. We focused on our self-pay patients and transports lacking complete demographic or insurance information. The goal was to eliminate manual steps and workflow lags—which we quickly achieved.
The original process involved building a list, submitting it to Payor Logic, waiting three days for feedback, and then re-entering information into our billing system. By bringing our vendors together to meet with our team, a real-time technology solution was developed and implemented.
Now our insurance verification team has immediate access to Payor Logic’s search capabilities. Insurance discovery is an online, real-time process. Lists, batches, searching websites and waiting for results have all been eliminated. Also, the two vendors built a crosswalk that integrates insurance coverage results back into our billing system to eliminate duplicate data entry and rekeying.
The productivity our verification team is now able to achieve is amazing. They now do the work of three staff with only two employees—a 30 percent boost in staff efficiency for insurance verification.
Billing also Gets Tech Boost
At Mohawk, we use a combination of technology solutions to support our revenue cycle. But each company worked independently—creating separate silos. Billers would have to search across several different systems, payor websites and the digital pages to collate all the various demographic and insurance data required to submit a claim. We had technology, but the process remained cumbersome and labor intensive.
By working with our vendors, we built points of integration to increase the number of claims processed without adding billing staff. For example, once a biller pulls up a trip, dozens of data elements from the billing system are uploaded into a single view to eliminate searching and save time.
Everything the biller needs to complete a claim is displayed in a consolidated view, consistent across all Mohawk companies. Billers can easily see patient signature, facility signature, narrative, vital signs, advanced life support and more. This level of integration eliminates the need to look at every page of the system to build the claim—saving dozens of hours every week.
Lessons Learned
Like most EMS providers, our mission is to uphold the highest standard of services with consistent devotion to delivering superior emergency medical care. And through this automation project, we took service excellence one step further—delivering world-class service throughout our billing process. We find more insurance coverage, reduce eligibility-related rejections, convert self-pay accounts and collect more revenue from the right source. Results thus far include:
- 30% improvement in staff efficiency for insurance verification
- 67% less time needed per case to screen for Medicare deductibles
- 100% elimination of wait times to discover billable insurance for self-pay patients
EMS providers looking to streamline the billing process should revisit their existing technology applications and engage in serious discussions with current vendors. New capabilities are out there and should be explored. The automation efforts described above have resulted in an efficiency uptick for Mohawk, despite being short staffed. New workflows for verification are being maintained by our team and next steps for automation expansion are being discussed. By keeping open communications and an ongoing dialogue with all parties involved, this automation experience has been a win-win for our business, our staff and our patients.
Maintaining Compliance Within an EMS Service
Maintaining compliance within an EMS service can be a daunting task, especially given the number of regulations that we must follow.
One way to look at EMS is if a trucking company married a hospital.
There are rules and regulations to abide by for an entire fleet of vehicles, from safe operation guidelines all the way down to the use and color of lights. Then there are requirements for a group of healthcare providers, which include necessary certifications such as CPR and knowledge of pertinent life-saving skills.
Not only does maintaining compliance keep vehicles and equipment running smoothly, but it can offer employees valuable peace of mind and keep everyone focused on the same goals of providing the best care possible.
I like to consider compliance an investment in common sense.
Employees know what is expected of them at all times, and they know what type of support their employer will provide to keep their skills sharp. In turn, an EMS service gains from being in good standing with regulators and from an engaged, confident workforce.
The benefits of a strong culture of compliance are immense. An organization that lives and breathes compliance can help ensure a smooth-running operation that features top-notch communication and quality providers who offer excellent care.
Journey to Compliance
These six key ways ensure compliance will serve as a roadmap to a strong culture in your organization:
- Start from the top: Backing from leadership ensures a strong culture of compliance. For certification and education compliance to stick, it starts with the attitudes of upper management, such as the board of directors, chiefs, officers, and day-to-day operations staff. Leaders must actively support all compliance efforts, including regular compliance-related reports, approving policies and having a general knowledge of the rules that govern EMS providers. Without the right tone from the top, an EMS service’s compliance efforts are usually undermined and ultimately fail. This results in issues with governing bodies, payers, scheduling and staffing.
- Commit to resources: Having the right personnel and systems in place are both vital to creating a strong compliance culture. The organization’s compliance staff should have experience in directing compliance efforts and supporting the evaluation of compliance-related risks. When it comes to certifications and education, compliance is always black and white. Knowing how to evaluate and respond to operational issues is important to maintaining compliance and successfully operating an EMS service. Systems that provide information to assist the service in complying with its obligations are a necessity.
- Have the write stuff: Developing written policies and procedures for compliance programs and internal controls is essential to adequately address regulatory requirements and an EMS service’s specific risks. Having these policies and procedures in writing sets the expectation of what is required of both managers and employees. Assessing risks before drafting these programs will help identify key areas where controls are needed. A compliance program should include how a service’s policies can be implemented from an operational perspective. This will include internal controls and standard operating procedures.
- Provide education: Providing the training for your EMS employees gives them peace of mind that they will be in compliance and acknowledges that the service values them.
- Test the system: Subjecting procedures to an independent review and audit ensures the compliance system is working correctly. This review provides an evaluation of where the EMS service’s compliance efforts stand. It also offers an opportunity to correct deficiencies before an outside regulatory audit is performed.
- Communicate more: Communication is vital to all organizations, but it can be the most difficult piece of the puzzle to achieve. With compliance-related responsibilities, sharing information is very helpful and, in some cases, required. Communicating expectations within EMS training programs is imperative. Reporting compliance efforts and noting any deficiencies should be a part of a communication strategy, especially if your state has an active medical director and/or board of EMS.
What is Reddit? (And Why EMS Leaders Should Care)
If you were asked to name the top 10 most popular websites in the United States today, I’m willing to bet that you could guess most of them: they are, in descending order of Alexa page view rankings, Google, YouTube, Facebook, Amazon, Yahoo, Wikipedia, Twitter, Reddit, Ebay, and LinkedIn.
“Wait,” you may be asking, “what is ‘Reddit,’ and how can it be in the top 10 most popular American websites if I’ve never even heard of it?”
As a self-appointed cultural ambassador for the millennial-heavy EMS workforce, I’d love to give you a basic introduction. Seasoned Redditors, feel free to skip this post. But those new to Reddit, or even social media in general, please hang in there—it is increasingly important for ambulance executives of all age groups and technology skill levels to “get” what is going on in influential online communities.
What is Reddit?
Reddit describes itself as “the front page of the internet.” What does that mean?
Reddit (usually styled lowercase as “reddit,” but I’m capping for clarity) is an online community platform allowing users to anonymously share, comment, and vote on links, images, personal stories and more in topic-specific “subreddits.” A user’s self-selected subreddits are merged into a personalized feed, which is often very different than the generic Reddit Front Page generated from the posts voted best across the whole site.
Wildly popular with millennials, Reddit is one of the most engaged and active digital communities in history. Reddit communities’ collective taste-making influence drives modern pop culture and politics in unprecedented ways, and the popularity and sway of the site is only growing.
I am sticking mostly to practicalities in this post, but highly recommend reading a little bit about the history of Reddit (2014 Mashable article, 2016 WSJ CEO interview), if you have a moment. The Wikipedia entry also gives a great overview.
Why should EMS leaders care?
Large swaths of your staff are routinely participating in Reddit communities, likely many times per week. For all that we hear about generational conflict in EMS organizations, wouldn’t it be great to gain some firsthand insight into the candid thoughts of EMTs and Paramedics across the country? Of course this only works if leaders approach Reddit (and the subs and threads of varying merit within) with an open mind—because of its inherently populist and anonymous nature, there is an ever-changing mix of valuable and abhorrent content that sometimes takes a little time to sort through.
Additionally, more and more people are electing to get their news, pop culture, and entertainment first through Reddit or other social media, instead of mainstream news sources. EMS leaders relying solely on information from TV newscasts or even the websites of traditional print journalism outlets are missing the backchannel dialogue and meta commentary that is shaping the way our industry is perceived.
Can Reddit participation help with EMS advocacy?
Many ambulance execs are unfamiliar with the fact that top politicians as diverse as President Obama and Gary Johnson choose to interact directly with Redditors, personally fielding user questions in the r/IamA sub. Reddit’s political commentary subs are also famed for the sometimes prescient, sometimes wacky user analysis of current affairs and election hoopla. Start with r/politics, the largest sub, to get a feel for the Reddit politosphere, then find your niche in some of the more targeted subs below. Not seeing your interest? Search the site for hundreds of other options ranging from radical to reactionary—or start your own.
How can I get started on Reddit?
We all have that kooky relative who doesn’t “get” Facebook, and so posts inappropriate rants or the equivalent of text voice mails on our walls. Don’t be “that guy” (or gal) on Reddit—although most people are nice, not everyone is patient, and some users may report your post to moderators for removal. Also, it is just good manners to follow the norms of any community in which you participate, be it face-to-face or online. Here are some easy steps to ensure that you become a valued contributor to the Reddit community.
- Create an account. Note: Do not use a variation of your real name or company name in your username. This is not Facebook, or even Twitter. It is crucial that unless you are a world leader (u/PresidentObama), celebrity (u/GovSchwarzenegger, u/williamshatner), or other very public figure (u/thisisbillgates, u/ColChrisHadfield) that you keep your personal information as private as possible for your own safety.
- Curate your subs.
- Login to reddit, then visit your subscription page to remove yourself from any default subs that don’t interest you. For me, this meant immediately axing everything related to sports (sorry, I mean, “Go Sox!“).
- Next, find and subscribe to many subs that interest you. There are thousands of subreddits for everything from r/cooking to r/gardening to r/motorcyles to r/parenting to r/books, and that is just scratching the surface. Typically large, general-interest subs will list more niche subs in their sidebars to make them easy to find.
- Lurk and get used to voting. Read your feed, or peruse a specific sub in-depth, upvoting posts and comments based on quality, not your level of agreement with the poster’s opinion. Typically, it is best to lurk (read without posting) for a month or two before you leap into the fray to get a sense for how each community interacts.
- Start posting and commenting. Now that you have some context for the types of conversations going on in your favorite subs, you’re ready to start submitting new posts and commenting on the posts of others, in addition to voting. It is really important to read Reddit’s content rules and Reddiquette guidelines, as well as the sidebar rules for your particular sub, before posting. Also, it is pretty much universally forbidden to share with the group any personally identifying information, even about yourself. Don’t get overwhelmed—most of the rules are common sense, and the time investment will pay off when you experience the thrill of sharing ideas and news with like-minded people from around the world.
Are there EMS-specific subs?
There are many EMS-focused subreddits, ranging from the (mostly) serious to the ridiculous. Here are just a few:
- r/EMS – by far the largest, with 21k subscribers as of today. Diverse mix of jokes, personal stories, protocol questions, opinions on employers, and more.
- r/RealEMS (2k subscribers) and r/TalesFromEMS aka r/TFEMS (3k subscribers) smaller subs focused on the perceived “real” side of EMS.
- r/911Dispatchers – (2k subscribers) – Sub targeting dispatch professionals.
- r/EMScringepics, r/LookImAFireFighter, etc – smaller subreddits where some popular EMS sartorial choices are mocked. Very definitely Not Nice, but may strike your funny bone if you have a certain sense of humor.
- r/firefighting (11k subscribers) – sub serving firefighters, but often touches on EMS topics
Hint: Sort by “TOP” then choose a timeframe to catch up on the best (or at least most popular) posts in a particular sub.
My service is mentioned on Reddit in a negative manner. Should I respond?
If someone posts something negative on Reddit (or Facebook, or Twitter, etc, etc) about the organization to which you’ve dedicated so much time and love, it can be very tempting to fire off your side of the story in response. However, it is almost always inadvisable to go in “guns blazing” on an anonymous message board, particularly if you aren’t very familiar with the norms for the specific sub in which you would respond.
If you really feel you must set the record straight, I suggest asking three other sensible Redditors and your attorney to review before posting, to make sure that you don’t accidentally open your organization up to a lawsuit or media nightmare. You may also want to create a separate “throwaway” username before replying, as anything you’ve previously commented or posted under your usual username is publicly visible. No matter how innocuous your past activity may be, it can and will be used against you in the court of public opinion (see: Ken Bone Reddit controversy).
My service is mentioned on Reddit in a positive manner. Should I respond?
In this case, it is a hard maybe. The tricky thing is that you want your organization to avoid being perceived as “Big Brother,” particularly in response to anything (good or bad) that might have been posted by one of your own employees. Given Reddit’s higher level focus on anonymity than, say, Facebook, even a “thanks so much, so glad to be your favorite employer!” reply can seem creepy or intrusive, depending on context. It may be best to just privately enjoy the knowledge that thousands are reading your unsolicited praises (and likely looking for job openings at your service).
If there are no HIPAA or human resources concerns involved, you can enlist the help of seasoned Redditors in crafting a response that is right in tone for your service.
Can I market my ambulance service on Reddit?
Commercial self-promotion of any kind is very much frowned upon by the Reddit community. Viral marketing, or any post planting or vote manipulation that can be perceived as viral marketing, even more so. For a glimpse at the level of energy around this issue, please see r/HailCorporate, or consider the vitriol directed at users who create alternate “sockpuppet” accounts to upvote their own posts. Any kind of advertising outside of appropriate subs that specifically allow it (or actual Reddit ads) is risky at best, and may completely backfire.
Can I post job listings to Reddit?
Read the sidebar rules of the subreddit you’re considering posting in to see if commercial offers are permitted (for example, counter-intuitively, r/jobs forbids job postings). Your may wish to consider posting to one of the subs dedicated to job seekers, including r/jobopenings, r/youngjobs, and r/jobbit, or your closest local job sub.
Another thing to consider is buying an ad on the Reddit site, then running it in EMS-specific subs, particularly if you’re open to paying relocation for medics from other areas, or if you are willing to train individuals coming from other industries.
Note: recruitment is not yet a primary Reddit focus, so you may or may not have much luck at this point. However, as more people join Reddit and rely on it new and different ways, this is likely to change.
Glossary
- Default sub—Default subreddits are subs considered to have the right mix of popularity and quality to be automatically included in new users’ subreddit subscriptions. You can remove default subreddits that you are not interested in following on your subscription page after you create a login.
- Karma—When a post or comment is submitted, other users can vote it up or down. “Karma,” divided into post karma and comment karma, is a loose indicator of the quality of a thread. You can track your own karma on your profile page, but it has no monetary or other value. In theory, voting is supposed to be based on the quality and relevance of the post or comment, but this doesn’t always play out perfectly. Some users have high overall karma scores because they post very relevant articles or incredibly insightful posts, others because they draw sketches or write poems related to posts, and still others because they are known for submitting posts or comments that the community finds funny.
- NSFL—an initialism for “Not Safe for Life.” This is used in the title of a post to indicate offensive content that shows or makes reference to gore, death, serious injury, the abuse of animals or people, etc. I would very strongly suggest that even the most hardened EMS folks stay away from most of these posts and the comments sections about them—NSFL posts do not bring out the best in humanity.
- NSFW—an initialism for “Not Safe for Work.” This is used in the title of a post to potentially sensitive content involving any kind of nudity or sex. Depending on context and the subreddit in which it is posted, this flag can be used for posts covering everything from a news photo of the Janet Jackson Super Bowl wardrobe malfunction to actual pornography. Use your best judgment.
- OP—like most other internet forums, on Reddit “OP” refers to “original poster,” and is a generic term used in comments to refer to the creator of the thread you’re currently reading.
- Meme—Most folks have probably heard of memes (pron. “meems”, not “meh-mehs,” “me-mes,” etc), or may even have shared some around the office or on Facebook. Reddit has a variety of inside jokes and memes specific to the community. If someone replies to a post with something that seems like a total non-sequitur, but others seem to find it funny, you may want to Google for inside jokes or check Know Your Meme for answers. Be forewarned: while some are funny or insightful, many memes and Reddit inside jokes are crass, prejudiced, or just stupid.
- Reddiquette—Reddit’s own set of community manners. Read it here before posting!
- Sub / Subreddit—Although originally not officially recognized, “sub” or “subreddit” are now almost universally used terms refers to self-moderated community centered around a particular topic. Here are just a few examples of the tens of thousands of subs you can choose to subscribe to, depending on your interests.
Have questions about Reddiquette or other social media platforms? Please don’t hesitate to reach out at ariordan@ambulance.org. Please feel free to share your own tips in the comments section below. We would love to hear about your ambulance service’s online successes and foibles.
Cataldo Ambulance’s Ron Quaranto on Mobile Integrated Health
As a current mobile integrated health provider, we recognize the values of an MIH program which most importantly provides quality patient care to those in need, often in the comfort of their own homes. This is often done under the direction of the patient’s primary care physician in conjunction with the patient’s healthcare team. This allows for the patient to maintain their quality of life while receiving the medical attention they need—and ultimately reducing the healthcare expenses of hospitalization.
Ron Quaranto
COO, Cataldo Ambulance Service
Save big on ZOLL with Savvik!
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Savvik Discount on Physio-Control
The American Ambulance Association is pleased to announce that AAA members can now save significantly on Physio-Control products through the Savvik Buying Group.
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Credit Card Processing: Interchange Plus vs. Tiered Pricing
When it comes down to the pricing structures offered by different credit card payment processors, how do you determine which is best for your ambulance service? The American Ambulance Association has teamed up with Payline Data to kick confusion to the curb.
Tiered Pricing Structure
Tiered pricing is a rate structure in which several hundred different processing rates are packaged into tiers that represent three different possible rates. Most providers package the rates into three groups with varying markups. Unfortunately, there is no regulation behind how merchant account providers must package their tiers, which prevents merchants from knowing exactly how much a given provider is making on each transaction. Despite the prevalence of tiered pricing in the credit card processing industry, a more competitive and transparent pricing model is available in the form of Interchange-plus pricing.
Interchange-Plus Pricing
Interchange-Plus pricing is the most transparent pricing model and it’s what Payline offers to all AAA members. This model for pricing puts the power in your hands by giving you a straightforward and clear explanation of charges. Interchange describes the rates that come directly from the card networks. No merchant or processing company has any control over these rates. Every merchant pays interchange, which varies based on the type of card your customer is using. The plus is what Payline is charging you for our service. It is our profit and is shown in terms of a small percentage markup and a minimal transaction cost.
The best-fit pricing structure is one that is designed to help your business thrive. To hear more about our exclusive pricing option for AAA members, call our friendly Payline representative for a free, no-obligation quote today.
Contact
Steve Marshall
Director of Corporate Partnerships
smarshall@paylinedata.com
(800) 284-7401
Your membership is important to us–let us know what you think of your Payline experience!
Choosing a Credit Card Processor for Your Ambulance Service
In the fast-paced life of an American Ambulance Association member, taking the time to evaluate credit card processing needs for can feel like a daunting task. The idea alone is enough to make some emergency vehicle businesses stick with the same old merchant processor when, unbeknownst to them, they are likely losing out on value added services and low rates that could help their business grow. Here are a few tips for choosing a credit card processor for your organization that will enhance your business operations:
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Understand Credit Card Processing 101
Credit card processing can seem like a complicated industry, and while it’s true that payments aren’t always black and white, a quality payment processor will help you understand the gray area. Credit card processing is essentially the backend work that occurs every time your business runs a credit or debit card transaction. The first part of the transaction is known as authorization (getting approval from the bank for the transaction) and the second part is settlement (processing of the actual sale, in which funds are transferred from the issuing bank to the merchant account). What it boils down to is this: payment processing is the expansion of your commerce reach as a business, and having one is necessary to optimize your business’s growth. (MORE: Read AAA’s EMS Card Payment Processing Guide)
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Make sure your processor is advocating for you and your business
It’s no secret that finding a best-fit business solution for your business takes time and careful consideration. It’s likely that there are many players are involved in helping you make business decisions, so it’s important to have a merchant advocate when selecting a payment processor. A quality payment processor for your business will provide you with an analysis of your recent processing statements and pinpoint where you might be able to cut costs. Money saved on processing can in turn be invested into growing your business and expanding your client reach.
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Find a processor with cutting-edge solutions
Any business that accesses debit and credit cards for payment is equally affected by the threat of fraud. A credit card processor that is truly beneficial to your business will seek out the right value added services that can assist you in the fight against fraud. With the new EMV chip cards that are being circulated, it’s important to consider the need for a terminal that can accept all types of cards. Other services offered by the best processors include ACH processing, USB readers, mobile readers, and cloud-based solutions. As commerce rapidly adapts to today’s merchant and consumer needs, your business needs a processor that will offer these solutions and more.
Sticking with a processor that isn’t providing you with the support your business needs isn’t worth your time. To learn more about credit card processing solutions that can help your business grow, contact Steve Marshall at Payline.
Contact us today via email or by phone (800) 284-7401 and we would be glad to run a statement analysis to show you how you can save money and cut costs on processing fees for the betterment and growth of your business.