Bill me

I got to sit in on a meeting with our billing company the other day and had a nice little discussion about what constitutes an ALS call.

In their non-clinical world only a call where a person performs an ALS skill is an ALS call.

I couldn’t disagree more.

I see what they’re going for, thinking about justifying our ALS rate for the guy who claimed to be suffering a stroke, but got no treatment.

But WHY did he get no treatment?  Because of a good ALS assessment.  That, to me, makes it an ALS call.  If we get on the scene with a BLS engine and they’re able to determine the transport is BLS, great.  Trouble is I have no BLS cars in my fleet, so even if I stick an EMT in the back I still have a Medic driving.  Plus there’s the stickler that the regulatory agency requires an ALS assessment on all patients.

So there we were, arguing whether or not running an EKG is an automatic ALS transport, him taking the side that it can’t be because it didn’t show anything and me arguing that that’s the entire point.  ALS isn’t the tools we carry or the skills we practice, it is our assessment skills.

I can train a cat how to intubate, but I can’t train him when not to.


Our assessment skills are what make the difference between a BLS and an ALS patient.  Plenty of ALS patients can be treated with BLS in the short term, sure, let’s not get into a BLS vs ALS pissing match, but instead shift our focus from what’s in the toolbox to when and WHY to use what’s in there.


Discussion finished, and me having lost, I wondered about the inefficiency of an all ALS transport system.  Perhaps I can convince the state and County to open their minds to alternate options.  We already transport to a specific alternate facility, perhaps more research is in order?


Just hope I can bill it at the ALS rate.


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8 thoughts on “Bill me”

  1. Maybe you should point out that when you get a doctors visit, they don’t charge you BLS rates when they take a temp and vitals.  They charge you doctors rates for the time.  Sure, the doctor didn’t perform any “Doctor” skills, but he gave you an MD/DO assessment.

  2. That interpretation is not consistent with Medicare guidelines.  Necessity for ALS is determined at the time of dispatch – if MPDS recommends ALS (C, D, or E calls), then ALS can be billed based ONLY on the paramedic assessment.  BLS calls (A or B) can be billed ALS only if ALS procedures are performed. The ALS assessment isn’t enough on calls where BLS is indicated because there was not need to send a paramedic in the first place.  (And before you go off on MPDS not being accurate, our own peer reviewed research – Hinchey, Zalkin et al – showed that 99.5% of the time an alpha call did not require any ALS intervention.

    No, you can’t change that by going “all ALS.”  Medicare (and all the others mostly follow Medicare) only pays for what is necessary.  Our system is all ALS, but the above still applies.

    So your billing contractor is costing you money.

    You DO need a good dispatch system and a good PCR system to make this work, but if you have that data it is a simply algorithm to apply.

  3. What Skip said. That. Exactly. Only he wrote it better than I would have. Medicare has a billing category for “ALS assessment” I can’t believe your billing company isn’t using it

  4. You need a new billing contractor. I had to learn a lot more about ambulance billing than I wanted to when I was on an administrative assignment in HQ. It didn’t start out that way, but what I was doing “blossomed” and I spent way too much time at billing meetings.

    I believe the term is “Condition at Dispatch”, which means what the caller told the call taker made the call taker enter it as an ALS call. As long as the ALS crew  did an ALS assessment, it can be billed as an “ALS 1″. At least that’s how I remember it. I think that even extends to cardiac arrest calls where the patient is determined to be non viable for resuscitation.

    I was also told, although I never verified it, that if you use a third person to drive, you there is an item for that.

    And that if you had to use an intermediate device to move the patient from where they were to the stretcher (stair chair, scoop, back board) that was a billable item.

    Skip is right, even though you are an “all ALS” system,  you can’t bill all transports as ALS. Dallas FD was doing that and ended up getting sued by CMS for over billing. They tried the defense of “we staff our ambulance with all paramedics, so all transports are ALS”. Not so much according to CMS. They settle for a small proportion of what the initial complaint was, but it was still expensive.

    Finally, maybe you should consider adding some BLS ambulances to the mix.

  5. I forgot to mention that we get paid for what we do, not for what we know. And we generally only get paid if we do a skill AND transport.

    The first step would be to get paid for doing stuff and not transporting, like fixing hypoglycemic patient.s Then, we can work on transporting patients who need to be in the hospital and need an ALS assessment, but don’t need defib, IV, ETT, etc…

  6. Happy, no matter what the transport in my county here in Annapolis, Maryland, AA County bills $500 no matter whether it’s ALS/BLS or BS!  They do not make county residents pay, if you have insurance, you give them that information, they bill your insurance company.  If not, well then have a nice day.  When I lived in Georgia, we had Rotten Metro as the ambulance where I lived most of my 10 years there.  And they bill by the mile, the amount of 02 administered, how many other things they might do.  And they don’t play with ANY insurance companies in Georgia, so you’re ALWAYS going to have to pay something out of pocket.  I told them to pound sand, they got $1400 from my insurance company, for a 3 mile transport, BLS, no lights and siren.  I’m much happier to be in MD where it is much easier.

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