POLICY FOR AMBULANCE FEE APPLICABILITY

PURPOSE 1. The City of Brentwood recognizes the need to bill patients for the provision of emergency medical services and transportation to aid in the provision of those services. 2. No person requiring emergency medical services and/or transportation shall be denied services due to a lack of insurance or ability to pay levied charges. 3. It is in the best interest of the residents of the City of Brentwood to establish a policy for EMS billing in accordance with the Health Care Finance Administration (HCFA) guidelines (as same may be from time to time amended or supplemented) so that individuals who legally reside in the City of Brentwood will not be responsible for the payment of any uninsured out-of-pocket expenses. BILLING FOR SERVICES a) All patients, whether they do or do not reside in the City of Brentwood, and/or their financially responsible parties, insurers or carriers, will be billed for emergency medical services and transportation provided by the Brentwood Fire Department according to a fee schedule established by the Mayor and Board of Aldermen of the City of Brentwood. b) A patient who receives emergency medical services or transportation from the Brentwood Fire Department is obligated, at the time of service or as soon as practicable to provide all pertinent identification, insurance and/or payment information to facilitate the City’s bill of third party payment sources for services rendered. The City of Brentwood may, at its option, and shall, where required by law, bill insurers or carriers on a patient’s behalf and accept payment on an assignment basis. c) All patients who do not legally reside in the City of Brentwood shall be liable for any copayment or deductible amounts not satisfied by public or private insurance, and the City shall make reasonable collection efforts for all such balances according to the most current rules or regulations set forth by applicable Health Care Financing Administration federal policies and regulations. Exceptions include only those instances where the City of Brentwood has knowledge of a particular patient’s indigence or where the City of Brentwood has made a determination that the cost of billing and collecting such copayments or deductible exceeds or is disproportionate to the amounts to be collected. d) The City of Brentwood shall not bill any individual legally residing in the City of Brentwood for any fee, balance, deductible or copayments not satisfied by public or private insurance, including Medicare/Medicaid, nor will the City of Brentwood bill an individual who

legally resides in the City of Brentwood for emergency medical services, provided that the individual is not covered by private or public insurance. e) The City of Brentwood may, either directly or through any third-party billing agency with which it has contracted for billing and/or collections for emergency medical services, make arrangements with patients and/or their financially responsible party for installment payments of bill or forgive any bill or portion thereof, so long as the City of Brentwood determines that: 1)

The financial condition of the patient requires such an arrangement; and

2)

The patient and/or financially responsible party have demonstrated a willingness to make good-faith efforts towards payment of the bill.

f) A patient who has received emergency medical or transport services from the City of Brentwood Fire Department, including an individual who legally resides in the City of Brentwood, for who the City of Brentwood has not received payment from a third-party payer on assignment, and who receives payment directly from a third-party payer for emergency medical services rendered by the Brentwood Fire Department, is obligated to remit such monies to the City of Brentwood in the event the City of Brentwood has not been paid for services rendered. Patients who do not remit such monies may be held liable for costs of collection in addition to the charges for emergency medical services rendered. PROCEDURE FOR THIRD-PARTY EMS BILLING a) The City of Brentwood is hereby authorized to enter into a contract with a third-party billing agency for performance of EMS billing and collection services; provided, however, that the following standards for such third-party billing contracts are met: 1)

The third-party billing agency has in place a compliance program conforming to standards set forth in the Inspector General’s Compliance Program Guidance for Third- Party Medical Billing Companies, 63 Federal Register 70138, as amended.

2)

Neither the billing agency nor any of its employees are subject to exclusion from any state or federal health-care program.

3)

The billing agency is bonded and/or insured in amounts satisfactory to the City of Brentwood.

b) A detailed listing of patients who are transported by the Brentwood Fire Department will be compiled by the Brentwood Fire Department. This information will be transmitted to the third-party billing agency. The information will be subject to the confidentiality requirements of applicable law. This information will include, at a minimum, the following: 1)

Name, address, and telephone number of patient.

2)

Name, address, and claim number of insurance carrier, if applicable.

3)

Date, time, and Brentwood Fire Department EMS run number.

4)

Point of origin and destination.

5)

Odometer reading at point of pickup and destination.

6)

Reason for transport/patient’s complaint/current condition.

7)

Signature of the patient or authorized decision maker.

8)

Name of receiving nurse.

9)

Names, titles, and signatures of EMS personnel when possible.

c) The third-party bill agency shall obtain the information from the Brentwood Fire Department and will bill the patient and/or his/her financially responsible parties, insurers or carriers, according to the fee schedule established herein: provided, however, that the third-party billing agency shall not bill any individual who legally resides in the City of Brentwood for any fee, balance, deductible, or copayments not satisfied by public or private insurance, including Medicare/Medicaid, nor will the City of Brentwood bill an individual who legally resides in the City of Brentwood for emergency medical services or transport, provided that the individual is not covered by private or public insurance. d) Invoices from the third-party billing agency shall be sent in accordance with the following procedure: 1)

There shall be a total of four invoices sent. If there is no response to the first invoice, a second invoice is sent at thirty days, if no response to the second invoice a third invoice is sent at thirty days. If no response to the first three invoices a forth, pre-collection invoice shall be sent at fifteen days. If, there is no response at ten days a final letter shall be sent notifying the patient they are being turned over to collections.

e) The third-party collection agency shall handle collections of unpaid invoices in accordance with the following procedure: 1)

A collection letter shall be sent every 30 days for 6 months (180 days). If after 90 days without a response, Credit Bureau Reporting (CBR) starts. After 180 days no more calls or letters are sent though the consumer can still make payments.

f) The fee for emergency medical services, transport miles per trip shall be established by the Mayor and Board of Aldermen (Attachment 1).

g) The Mayor and Board of Aldermen shall review the fees for service listed in Attachment 1 periodically and adjust said fees based on the recommendations of the Finance Director and in accordance with the federally approved Medicare fee schedule. h) The City Administrator may promulgate rules and regulations pursuant to and not inconsistent with this policy, state and federal law, and such rules and regulations, which rules and regulations shall become effective upon approval by resolution of the Brentwood Board of Aldermen. PROCEDURE FOR UNCOLLECTIBLE CHARGES a) Accounts that are deemed to be uncollectible shall be presented to the Ways and Means Committee on a quarterly basis for approval to write-off. b) Accounts that have been approved to be written-off by the Ways and Means Committee shall be presented to the Board of Aldermen for final approval. c)

Uncollectible ambulance charges are classified as follows: 1)

Charges for Brentwood residents in excess of amounts allowed by Medicaid, Workers Compensation and Hospice Care, which are not covered by any secondary insurance, will be accepted as payment in full and any co-payment amounts will be written off.

2)

Charges for Brentwood residents specified by Medicare as adjustments to the amounts paid will be written off.

3)

Charges billed as private pay and to private insurance providers or other thirdparty payers that remain unpaid after the completions of the collection process and the likelihood of collection appears remote because of difficulty in locating responsible party or other related reason.

4)

Balances of less than $10.00 will be written off as being uncollectible.

5)

Charges provided a patient whose name and/or address is unknown, or upon whom there is otherwise insufficient information to locate the patient, or a patient using a false name and/or address, or a patient who is a minor and whose parents or next of kin are unknown, or there is otherwise insufficient information to locate the parents or next of kin.

6)

Special hardship cases of horrific death, permanent, partial or total disability or ruinous dismemberment.

7)

Special hardship cases of war, terrorism, or natural disasters.

8)

Charges for transports which are more than one year old and which have been pursued by all means possible will be written-off as uncollectible.

9)

Settlements that are governed by State Statue and Missouri Lien Laws.

Attachment #1 - City of Brentwood Ambulance Charges - 2013 Charge

HCPCS

Expected Amount

Start Date

End Date

12 Lead EKG Monitor-BR

93000

$75.00

N/A

N/A

Adenosine-BR

J0150

$125.00

N/A

N/A

Albuterol-BR

J7618

$25.00

N/A

12/31/2005

Albuterol-BR

J7620

$25.00

1/1/2006

N/A

ALS 1 Emergency (non res)-BR

A0427

$650.00

N/A

N/A

ALS 1 Emergency (res)-BR

A0427

$650.00

N/A

N/A

ALS 1 Emergency-BR

A0427

$400.00

N/A

4/30/2003

ALS 1 Emergency-BR

A0427

$425.00

5/1/2003

5/16/2005

ALS 1 Emergency-BR

A0427

$650.00

5/17/2005

N/A

ALS 2 Emergency (non res)-BR

A0433

$650.00

N/A

N/A

ALS 2 Emergency (res)-BR

A0433

$650.00

N/A

N/A

ALS 2 Emergency Base-BR

A0433

$400.00

N/A

4/30/2003

ALS 2 Emergency Base-BR

A0433

$425.00

5/1/2003

5/16/2005

ALS 2 Emergency Base-BR

A0433

$650.00

5/17/2005

N/A

ALS Mileage-BR

A0425

$5.00

N/A

5/16/2005

ALS Mileage-BR

A0425

$6.00

5/17/2005

12/31/2008

ALS Mileage-BR

A0425

$7.00

1/1/2009

N/A

ALS1 Non-Emergency (res) - BR

A0426

$650.00

N/A

N/A

ALS1 Non-Emergency(non-res)-B

A0426

$650.00

N/A

N/A

Atropine-BR

J0460

$21.00

N/A

N/A

Baby Aspirin-BR

A0999

$1.00

N/A

N/A

Benadryl up to 50mg-BR

J1200

$18.00

N/A

N/A

BLS Emergency - BR (Non-Res)

A0429

$650.00

N/A

N/A

BLS Emergency - BR (Res)

A0429

$650.00

N/A

N/A

BLS Emergency-BR

A0429

$650.00

N/A

N/A

BLS Mileage - BR

A0425

$6.00

N/A

12/31/2008

BLS Mileage - BR

A0425

$7.00

1/1/2009

N/A

Defibrillation-BR

A0392

$30.00

N/A

N/A

Dextrose 50%-BR

J7042

$24.00

N/A

N/A

EKG Monitor-BR

93040

$50.00

N/A

N/A

Epinephrine 1:10000-BR

J0170

$18.00

N/A

12/31/2010

Epinephrine 1:10000-BR

J0171

$18.00

1/1/2011

N/A

Epinephrine 1:1000-BR

J0170

$20.00

N/A

12/31/2010

Epinephrine 1:1000-BR

J0171

$20.00

1/1/2011

N/A

First Aid Supplies-BR

A0398

$30.00

N/A

N/A

Fracture Immobilization-BR

A0398

$20.00

N/A

N/A

Glucose Test-BR

A0398

$25.00

Intubation-BR

31500

Intubation-BR

A0396

IV-BR Lactated Ringers (1000 ml)-BR Lasix-BR Lidocaine-BR Medicaid Emergency No Serv-BR Medicaid Emergency No Serv-BR Medicaid Emergency No Serv-BR Medicaid Emergency No Serv-BR Morphine-BR Narcan-BR Nitro Spray-BR Normal Saline (1000ml)-BR OB Kit-BR Oxygen-BR Pulse Ox-BR Return Check Fee/BR Sodium Bicarb-BR Spinal Immobilization-BR Suction Airway-BR Updraft Treatment-BR Versed-BR

A0394 J7120 J1940 J2000 A0368 A0368 Q3019 A0427 J2270 J2310 A0999 J7030 A0999 A0422 A0398 J3490 A0398 A0999 A0999 J2250

N/A

N/A

$35.00

N/A

12/31/2005

$35.00

1/1/2006

N/A

$30.00 $20.00 $30.00 $21.00 $400.00 $425.00 $425.00 $425.00 $18.00 $20.00 $60.00 $5.00 $50.00 $30.00 $35.00 $25.00 $25.00 $30.00 $20.00 $25.00 $20.00

N/A N/A N/A N/A N/A 5/1/2003 7/1/2003 1/12007 N/A N/A N/A N/A N/A N/A N/A N/A N/A N/A N/A N/A N/A

N/A N/A N/A N/A 4/30/2003 6/30/2003 12/31/2006 N/A N/A N/A N/A N/A N/A N/A N/A N/A N/A N/A N/A N/A N/A