Payers of healthcare providers’ claims demand documentation in support of air ambulance services – emergency room staff must consider risk of denial.
Most healthcare practitioners are aware that hospital emergency departments are required by EMTALA to treat those patients who present with emergency medical conditions. Though not commonly noted, one important exception to EMTALA’s anti-dumping prohibition is the requirement for emergency department staff to transfer patients to higher level trauma facilities when needed services are not readily available. To ensure reimbursement of the transporter, and the sending hospital’s compliance with EMTALA, clinical rationales for such transfers must be well documented in the clinical record. This is particularly important in air ambulance inter-facility transfers to higher level trauma facilities.
Documentation is Critical.
It is axiomatic in American healthcare that “if it isn’t written, it didn’t happen.” The clinical chart must document clinical justifications to support diagnoses and decisions, and this tenet applies to clinical rationales relating to air transport decision. If not clearly documented, the transportation may not be reimbursed due to a lack of demonstrated medical necessity.
As attending physician recently testified at an administrative hearing involving the issue of reimbursement, his role sometimes seems more about “treating paper” than caring for patients. While patient care always comes first, documenting those actions is essential to supporting reimbursement, while also confirming that the transfer complies with EMTALA’s proscriptions against patient dumping.
It All Comes Down to Cost.
It goes without stating that cost considerations are main drivers for reimbursement decisions made by payers. This “Chevy Rule” is covered by Paralegal Karen Kizer in an earlier blog, describing where the patient’s care is reimbursable up to the point of medical necessity – but not more. In other words, if a Chevy suffices then a Cadillac is a non-reimbursable luxury.
Under this rubric, ground transport is the presumptive mode of transportation. Indeed, ground transport is appropriate for most inter-facility transfers, unless air transport is clearly supported in the patient’s condition. Within this context, consider inter-facility transport costs: transport by traditional ground ambulance is generally around $2,000 or less, without mileage. However, the charges assessed by an air ambulance company may be more than $25,000. But in some complicated and urgent cases, critical care air transport services may be the only clinically reasonable choice.
Medical Necessity is Still the Cardinal Rule. Document it.
In situations where air transport is appropriate, the medical record must clearly reflect the need for air transport. The higher level of critical care and cost inherent in air ambulance treatment prompts greater scrutiny. In Maryland, for example, Medical Assistance requires a physician to complete a certification for air transport. The form requires that a physician appropriately answer the following questions:
- What are the resources needed that are not available at the sending facility?
- Is the receiving facility the closest where such resources are available?
- Is the patient unstable?
- What level of transport is required?
- Is ground transport contraindicated – and if so, why?
Emergency department physicians should not wait for these forms to be handed to them to answer these important questions – often, well-after the patient has been discharged. Instead, answers to these questions should be fully documented in the clinical chart before the patient is transported by air. This best practice will help avoid improper denials of claims filed by transporters.
Summary: The Risk of Denial is with the Air Transporters.
Emergency room physicians must keep in mind that transport crews – whether be they ground or air ambulances – do not determine to transfer patients. Rather, their obligation to transfer a patient is based on the sending physician’s order. Nonetheless, the clinical rationale for the transportation decision impacts whether the transporter is reimbursed. If medical necessity criteria for the patient are not clearly documented, then the air transporter may be precluded from reimbursement – whether be it from a commercial payer or government plan, such as Medicaid.
Air transporters, as participants in a patient’s care, should be considered when making a decision to transfer a patient to a higher level of care.
Anderson & Quinn, LLC is a renowned law firm based in Rockville, Maryland, providing individuals, businesses, corporations, and healthcare institutions with the legal and litigation support they need.
