Hey, Box Jockeys!

This hose monkey has some questions for you.  Please answer honestly, anonymously if you like, but some things have been bothering Happy as of late.

Question #1

Does your employer discourage you from being honest with your patients when it comes to transport decisions?

Question #2

Has your employer asked you to omit information on your reports that would prevent billing a patient a certain way?

Question #3

If a patient asked your opinion, you told the truth and they refused care, would you be in fear for your job?

Question #4

Does your service encourage starting an IV or EKG monitoring for BLS patients to upgrade the billing?

Question #5

Are you aware that the above situations could constitute fraud?

If you are trying to decide whether to do what is right by your patient or keep your job, email me.  Your employer, municipal or private, paid or volunteer, is wrong and we need help changing their practices.

If you are comfortable and supported by your service when being honest with your patients about their conditions and transport options, please list your service in the comments section, they deserve praise.

ems2point0

HM

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48 thoughts on “Hey, Box Jockeys!”

  1. Current FD based employer:
    1. No
    2. No
    3. No
    4. No
    5. YES

    Former Private EMS service:
    1. Yes, they do.
    2. No.
    3. Possibly now, not then (if I still worked there).
    4. No.
    5. Still yes.

    I do know medics that have been told to do #2, & 4.

  2. Current FD based employer:1. No
    2. No
    3. No
    4. No
    5. YES

    Former Private EMS service:
    1. Yes, they do.
    2. No.
    3. Possibly now, not then (if I still worked there).
    4. No.
    5. Still yes.

    I do know medics that have been told to do #2, & 4.

  3. Current FD based employer:
    1. No
    2. No
    3. No
    4. No
    5. YES

    Former Private EMS service:
    1. Yes, they do.
    2. No.
    3. Possibly now, not then (if I still worked there).
    4. No.
    5. Still yes.

    I do know medics that have been told to do #2, & 4.

  4. OK here goes
    1 Absolutely not. Do we sometimes do “defensive EMS” (read anti-law suit) yes but that’s it
    2 No only no but hell no. We don’t f with that, the fear or lawsuit is severe around here
    3 No (but the owner of the private may get a little cranky, but no)
    4 No (both the volley fire based and the private special event only service)
    5 Yes

  5. OK here goes
    1 Absolutely not. Do we sometimes do “defensive EMS” (read anti-law suit) yes but that's it
    2 No only no but hell no. We don't f with that, the fear or lawsuit is severe around here
    3 No (but the owner of the private may get a little cranky, but no)
    4 No (both the volley fire based and the private special event only service)
    5 Yes

  6. 1-4, no. 5. I suppose if I thought about it, I would know it.

    As to EMS 2.0, I’m not sure I get the connection. In general with EMS 2.0, I don’t sense a unified idea of what the direction should be. I’ll have to think about that and then write a post.

    1. At this point EMS 2.0 is more of a searchable term so I can hit up google and see what other folks are hoping their future in EMS to be. For me it means putting the decisions in the hands of the only people who know what’s going on, the Paramedics at the scene.
      It means more education, it means tougher standards, but if that is what it takes to make this thing we think is patient care work, I’m for it.
      So, the connection for me is that in my EMS 2.0 I don’t get audited when I leave Bubba Fishbiscuit to go about his business when he didn’t need us in the first place. Not refusing care, yet, just weeding out the confused. I look forward to your thoughts.

  7. 1-4, no. 5. I suppose if I thought about it, I would know it.

    As to EMS 2.0, I'm not sure I get the connection. In general with EMS 2.0, I don't sense a unified idea of what the direction should be. I'll have to think about that and then write a post.

  8. Old private job:

    1. N/A, really.
    2. Yep.
    3. Somewhat.
    4. Never to me. In fact, for Medicaid patients, it’s prefered we BLS it no matter what it is, since the payout will be the same, and theoretically we’ll be back in service faster.
    5. Only if they actually submit the bill, which isn’t my decision or fault, really, if you think about it.

    POC 911 departmemt:

    1. It’s never really come up. I’m as honest as I can be without straying too far beyond my scope and knowledge.
    2. No.
    3. Department wouldn’t do anything, but I would likely spend an inordinate amount of time worrying about what might happen legally.
    4. No.
    5. Yes, but only because I’ve worked a private before. My collegues that haven’t, probably don’t.

  9. 1. No
    2. No
    3. No
    4. No, but we get a lot of scheduled transports that were dispatched as ALS that turn out to be BLS, because call taker did not get correct information. I chart it as BLS, but am not sure if they bill it ALS since that is what was ordered.
    5. Yes, and I would have no problem calling my company out on the carpet if they tried to pull this crap.

  10. The 8 private transport companies I’ve worked for all skated around the rules to some extent. A few were blantantly committing fraud. So far I’ve only seen one get caught, but they still got around it with some fines and are still in business. Since it was primarily scheduled transport; it wasn’t a question of whether to transport or not. They make us lie on the PCR so they get paid. Omit information, absolutely. One company told me to rewrite PCR’s that had been signed and turned in, when I refused I was fired the next shift. I hadn’t seen this with the counties until I came to the one I’m with now. They are doing scheduled transport to bring money in and it’s more of the same. We are forced to transport everyone we respond to no matter what the complaint. If we respond to a 911 call and don’t transport they have a FTO call the patient the next day to check behind us. I’ve been told we can be fired for not transporting a patient where ever they want to go. We’ve got the crazy frquent flier we have to transport an hour away when there is absolutely nothing wrong with him. It’s a business, money is the bottom line. What makes me insane is when the patients are mistreated and we can’t do anything to help them. Every transport company I’ve worked with has been much more concerned with keeping the facility pacified than with patient care. To some extent, I believe medicare/medicaid is at fault with this happpening. They create a paperwork nightmare that doesn’t lend itself to honesty if you want to get paid. If you go to the state EMS or medicare people and anyone finds out, well get ready to change occupations or move far away. The gossip/good old boy network is firmly entrenched and you cross them and you’re done. Welcome to the deep South!

    1. I appreciate your brutal honesty and I, more than most, feel your pain. However there are two things you said that I wonder about. I also realize that protocols and SOP’s are not multi-juristictional for the most part, so that could be the case…..

      1) You said that you are made to transport the patient to wherever they want to go. Doesn’t the “closest appropriate facility” come into play at all for your agency? Medicare/Medicaid will reimburse $9.00/mile but only to a certain extent without physician certification…just curious how this benefits the company if they’re giving “free” rides.

      2) MISTREATED PATIENTS?!?!?! There is ALWAYS a way to fix that problem. Facility pacification be damned. As an EMS provider we have a duty to advocate for the patients right to life, liberty and freedom from harm…what’s going on here? Social Services might be a good place to start if an assult or battery charge can’t solve the problem.

      1. Well for the first question, if it’s truly emergent (rare) closest approriate facility. Otherwise wherever the patient wants to go. Crazy frequent flier guy has restraining orders against him at all the local facilities, hence 60 mile ride.

        Question 2 this was primarily nursing home abuse/neglect witnessed with private transport. I tried to help but got severely popped for interfering up to and including fired. Horrific adventure this week—- morbidly obese paramedic unable to access patient in full arrest, salvageable patient and he died. I complained (almost) and my job is seriously on the line. Haven’t turned in official written complaint yet and they immediately informed her. She’s my asst. supervisor and I expect some ugly fallout. So stay tuned for more adventures from the deep south….lol. Y’all hiring?

  11. Old private job:

    1. N/A, really.
    2. Yep.
    3. Somewhat.
    4. Never to me. In fact, for Medicaid patients, it's prefered we BLS it no matter what it is, since the payout will be the same, and theoretically we'll be back in service faster.
    5. Only if they actually submit the bill, which isn't my decision or fault, really, if you think about it.

    POC 911 departmemt:

    1. It's never really come up. I'm as honest as I can be without straying too far beyond my scope and knowledge.
    2. No.
    3. Department wouldn't do anything, but I would likely spend an inordinate amount of time worrying about what might happen legally.
    4. No.
    5. Yes, but only because I've worked a private before. My collegues that haven't, probably don't.

  12. 1. No
    2. No
    3. No
    4. No, but we get a lot of scheduled transports that were dispatched as ALS that turn out to be BLS, because call taker did not get correct information. I chart it as BLS, but am not sure if they bill it ALS since that is what was ordered.
    5. Yes, and I would have no problem calling my company out on the carpet if they tried to pull this crap.

  13. In my part-time experience with local 911 ambulance service:
    #1 Sort of. They want us to be honest about patient volume and diversion status, but we’re supposed to transport anyone who wants it to anywhere they want to be transported to.

    #2 No

    #3 Maybe. The company doesn’t push “always transport,” but there is a heavy feel of “transporting is better than not.”

    #4 No because Medicaid isn’t going to pay for it. So, treatment is very much patient-specific.

    #5 Yes. If anyone had a problem with any of it happening.

  14. The 8 private transport companies I've worked for all skated around the rules to some extent. A few were blantantly committing fraud. So far I've only seen one get caught, but they still got around it with some fines and are still in business. Since it was primarily scheduled transport; it wasn't a question of whether to transport or not. They make us lie on the PCR so they get paid. Omit information, absolutely. One company told me to rewrite PCR's that had been signed and turned in, when I refused I was fired the next shift. I hadn't seen this with the counties until I came to the one I'm with now. They are doing scheduled transport to bring money in and it's more of the same. We are forced to transport everyone we respond to no matter what the complaint. If we respond to a 911 call and don't transport they have a FTO call the patient the next day to check behind us. I've been told we can be fired for not transporting a patient where ever they want to go. We've got the crazy frquent flier we have to transport an hour away when there is absolutely nothing wrong with him. It's a business, money is the bottom line. What makes me insane is when the patients are mistreated and we can't do anything to help them. Every transport company I've worked with has been much more concerned with keeping the facility pacified than with patient care. To some extent, I believe medicare/medicaid is at fault with this happpening. They create a paperwork nightmare that doesn't lend itself to honesty if you want to get paid. If you go to the state EMS or medicare people and anyone finds out, well get ready to change occupations or move far away. The gossip/good old boy network is firmly entrenched and you cross them and you're done. Welcome to the deep South!

  15. In my part-time experience with local 911 ambulance service:
    #1 Sort of. They want us to be honest about patient volume and diversion status, but we're supposed to transport anyone who wants it to anywhere they want to be transported to.

    #2 No

    #3 Maybe. The company doesn't push “always transport,” but there is a heavy feel of “transporting is better than not.”

    #4 No because Medicaid isn't going to pay for it. So, treatment is very much patient-specific.

    #5 Yes. If anyone had a problem with any of it happening.

  16. At this point EMS 2.0 is more of a searchable term so I can hit up google and see what other folks are hoping their future in EMS to be. For me it means putting the decisions in the hands of the only people who know what's going on, the Paramedics at the scene.
    It means more education, it means tougher standards, but if that is what it takes to make this thing we think is patient care work, I'm for it.
    So, the connection for me is that in my EMS 2.0 I don't get audited when I leave Bubba Fishbiscuit to go about his business when he didn't need us in the first place. Not refusing care, yet, just weeding out the confused. I look forward to your thoughts.

  17. i moved to the south from from well lets just say above the mason dixen line… I hate to say it but carolinagrl is dead on the money… i hate it but thats life down here, lookin to get out as fast as possible!

  18. i moved to the south from from well lets just say above the mason dixen line… I hate to say it but carolinagrl is dead on the money… i hate it but thats life down here, lookin to get out as fast as possible!

  19. Question #1

    Does your employer discourage you from being honest with your patients when it comes to transport decisions?

    A: Somewhat, the EMS director prefers we dont mention the pt having a choice of hospital. Though if the pt speaks up we will take them to their preference. We can discuss alternate options of getting to the hospital w/o getting in trouble.

    Question #2

    Has your employer asked you to omit information on your reports that would prevent billing a patient a certain way?

    A: Nope

    Question #3

    If a patient asked your opinion, you told the truth and they refused care, would you be in fear for your job?

    Always recommend transport to avoid lawsuits. :-(

    Question #4

    Does your service encourage starting an IV or EKG monitoring for BLS patients to upgrade the billing?

    A: No because our ALS1 and BLS rates are the same this avoids the above problem.

    Question #5

    Are you aware that the above situations could constitute fraud?

    Yes.

  20. Question #1

    Does your employer discourage you from being honest with your patients when it comes to transport decisions?

    A: Somewhat, the EMS director prefers we dont mention the pt having a choice of hospital. Though if the pt speaks up we will take them to their preference. We can discuss alternate options of getting to the hospital w/o getting in trouble.

    Question #2

    Has your employer asked you to omit information on your reports that would prevent billing a patient a certain way?

    A: Nope

    Question #3

    If a patient asked your opinion, you told the truth and they refused care, would you be in fear for your job?

    Always recommend transport to avoid lawsuits. :-(

    Question #4

    Does your service encourage starting an IV or EKG monitoring for BLS patients to upgrade the billing?

    A: No because our ALS1 and BLS rates are the same this avoids the above problem.

    Question #5

    Are you aware that the above situations could constitute fraud?

    Yes.

  21. Question #1Does your employer discourage you from being honest with your patients when it comes to transport decisions?Ans:NoQuestion #2Has your employer asked you to omit information on your reports that would prevent billing a patient a certain way?Ans:No.Question #3If a patient asked your opinion, you told the truth and they refused care, would you be in fear for your job?Ans:NoQuestion #4Does your service encourage starting an IV or EKG monitoring for BLS patients to upgrade the billing?Ans:Absolutely not.Question #5Are you aware that the above situations could constitute fraud?Ans:Yes.

  22. Question #1

    Does your employer discourage you from being honest with your patients when it comes to transport decisions?

    Ans:No

    Question #2

    Has your employer asked you to omit information on your reports that would prevent billing a patient a certain way?

    Ans:No.

    Question #3

    If a patient asked your opinion, you told the truth and they refused care, would you be in fear for your job?

    Ans:No

    Question #4

    Does your service encourage starting an IV or EKG monitoring for BLS patients to upgrade the billing?

    Ans:Absolutely not.

    Question #5

    Are you aware that the above situations could constitute fraud?

    Ans:Yes.

  23. We only have two billing amounts ALS or BLS. We only charge the ALS, if it’s needed. We don’t pad our bills (that I know of).

    Question #5

    Yes, which sucks.

  24. We only have two billing amounts ALS or BLS. We only charge the ALS, if it's needed. We don't pad our bills (that I know of).

    Question #5

    Yes, which sucks.

  25. I could honestly answer “No” to the above questions as they are asked, except to the last one which is of course “Yes”. But in a PI/QA context, things can often be said in a way that would defiantly “encourage” one to “reconsider” the way their respective duties are carried out and re-evaluate the manner in which decisions are made. (wink, wink)

    A couple of people above have mentioned that it may be a southern thing, uummm….could be. I dunno. There is one thing I’m most confident in and that is karma (or insert your form of retribution), in that it will effect everyone if they are involved in fraudulent activities. First to the employer if they are caught and also to the provider if they are fudging to make reports billable….it only takes one time before that one incident comes back baring teeth to bite you.

  26. I appreciate your brutal honesty and I, more than most, feel your pain. However there are two things you said that I wonder about. I also realize that protocols and SOP's are not multi-juristictional for the most part, so that could be the case…..

    1) You said that you are made to transport the patient to wherever they want to go. Doesn't the “closest appropriate facility” come into play at all for your agency? Medicare/Medicaid will reimburse $9.00/mile but only to a certain extent without physician certification…just curious how this benefits the company if they're giving “free” rides.

    2) MISTREATED PATIENTS?!?!?! There is ALWAYS a way to fix that problem. Facility pacification be damned. As an EMS provider we have a duty to advocate for the patients right to life, liberty and freedom from harm…what's going on here? Social Services might be a good place to start if an assult or battery charge can't solve the problem.

  27. I could honestly answer “No” to the above questions as they are asked, except to the last one which is of course “Yes”. But in a PI/QA context, things can often be said in a way that would defiantly “encourage” one to “reconsider” the way their respective duties are carried out and re-evaluate the manner in which decisions are made. (wink, wink)

    A couple of people above have mentioned that it may be a southern thing, uummm….could be. I dunno. There is one thing I'm most confident in and that is karma (or insert your form of retribution), in that it will effect everyone if they are involved in fraudulent activities. First to the employer if they are caught and also to the provider if they are fudging to make reports billable….it only takes one time before that one incident comes back baring teeth to bite you.

  28. Well for the first question, if it's truly emergent (rare) closest approriate facility. Otherwise wherever the patient wants to go. Crazy frequent flier guy has restraining orders against him at all the local facilities, hence 60 mile ride.

    Question 2 this was primarily nursing home abuse/neglect witnessed with private transport. I tried to help but got severely popped for interfering up to and including fired. Horrific adventure this week—- morbidly obese paramedic unable to access patient in full arrest, salvageable patient and he died. I complained (almost) and my job is seriously on the line. Haven't turned in official written complaint yet and they immediately informed her. She's my asst. supervisor and I expect some ugly fallout. So stay tuned for more adventures from the deep south….lol. Y'all hiring?

  29. Just catching up on the blogs now…

    YES to all. (Private service… only option here in La, unfortunately.)

    but… bad day for the boss- because I refuse to hurt our system further. I am honest with all patients, down to whether or not their call is truly an emergency. If my judgement states that the person needs an IV or EKG, I run one… but on a toe pain call? No.
    The list goes on.

  30. Just catching up on the blogs now…

    YES to all. (Private service… only option here in La, unfortunately.)

    but… bad day for the boss- because I refuse to hurt our system further. I am honest with all patients, down to whether or not their call is truly an emergency. If my judgement states that the person needs an IV or EKG, I run one… but on a toe pain call? No.
    The list goes on.

  31. The thing that kills me about my private service is the price differential between a BLS “stretcher transport” and an ALS “scheduled ambulance” – which is about $400, even though we only run ALS units. I can see some difference in fees if ALS interventions are needed, but if its an interfacility run with only an active IV, I can’t see the reasoning for charging so much more.

  32. The thing that kills me about my private service is the price differential between a BLS “stretcher transport” and an ALS “scheduled ambulance” – which is about $400, even though we only run ALS units. I can see some difference in fees if ALS interventions are needed, but if its an interfacility run with only an active IV, I can't see the reasoning for charging so much more.

  33. 1. Yes. If I was honest, I would tell half my patients to take some tylenol and go back to bed. Instead, per protocol, I have to offer them transport 3 at least times, explain the danger of not being immediately assessed by an ER physician, and have them sign an AMA form.

    2. Yes. We have required training each year that discourages us from using phrases such as “Pt ambulated to the gurney without assistance.” We are told to start our narrative with phrases like “Pt requires ALS transport because…”

    3. Yes. A paramedic in my county was recently fired, then rehired (after the union intervened) after he AMA’d a patient involved in an MVA who adamantly refused transport and later turned out to have a C3-C4 Fx. He thoroughly documented the pt’s refusal and she signed an AMA form though my company still tried to fire him when she sued. And he did nothing but tell her she needed to go to the hospital.

    4. No.

    5. No comment.

  34. 1. Yes. If I was honest, I would tell half my patients to take some tylenol and go back to bed. Instead, per protocol, I have to offer them transport 3 at least times, explain the danger of not being immediately assessed by an ER physician, and have them sign an AMA form.

    2. Yes. We have required training each year that discourages us from using phrases such as “Pt ambulated to the gurney without assistance.” We are told to start our narrative with phrases like “Pt requires ALS transport because…”

    3. Yes. A paramedic in my county was recently fired, then rehired (after the union intervened) after he AMA'd a patient involved in an MVA who adamantly refused transport and later turned out to have a C3-C4 Fx. He thoroughly documented the pt's refusal and she signed an AMA form though my company still tried to fire him when she sued. And he did nothing but tell her she needed to go to the hospital.

    4. No.

    5. No comment.

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