EMS Revenue Cycle Management

1. Verification and Authorization (Pre-Claim)

This crucial first step minimizes denials before a claim is even generated.

• Payer Eligibility Verification: We verify the patient's insurance coverage (Medicare, Medicaid, or commercial) in real-time to determine the correct primary and secondary payers and coverage status.

• Medical Necessity Review: Proactive review of documentation and trip circumstances against payer rules to confirm the claim meets "medical necessity" requirements, especially for non-emergency transports, preventing future denials.

• Prior Authorization Management: We obtain and manage all necessary prior authorizations required by certain insurance plans for non-emergent transports, ensuring compliance before transport takes place.

2. Documentation and Coding Integrity (Claim Generation)

Accuracy in coding is the foundation of successful reimbursement.

• AEMT/Paramedic Documentation Review: Our certified coders review Patient Care Reports (PCRs) to ensure all clinical procedures, supplies, mileage, and times are accurately reflected and supported by the narrative.

• ICD-10 and CPT Coding: We apply the correct ICD-10 diagnosis codes (justifying medical necessity) and CPT procedure codes (reflecting services rendered) to every claim, ensuring maximum compliant reimbursement.

• Modifier Management: Precise application of essential modifiers (e.g., origin/destination, necessity, level of service) to avoid common claim processing errors and rejections.

3. Claim Submission and Processing

Efficient, electronic submission speeds up the entire RCM process.

• Electronic Claim Submission (EDI): Claims are submitted electronically to all payers, including Medicare, Medicaid, and commercial carriers, reducing processing time and manual errors.

• Compliance Scrubbing: Automated systems pre-check claims against thousands of payer-specific rules and common error patterns before submission, drastically increasing the First Pass Acceptance Rate (FPAR).

• Secondary and Tertiary Billing: Automated submission to secondary and tertiary payers (e.g., Medigap, supplemental plans) to ensure full claim realization after the primary insurer has paid.

4. Denial Management and Appeals

The most critical differentiator in RCM is how denials are handled.

• Root Cause Analysis: We analyze denied claims to identify the precise reason (e.g., incorrect modifier, documentation gap, medical necessity issue) and implement corrective action immediately.

• Proactive Appeals: Our team prepares and submits compelling, timely appeals with all necessary supporting documentation to overturn inappropriate payer denials.

• Underpayment Recovery: We monitor Explanation of Benefits (EOBs) to identify and pursue instances where payers underpaid the contracted or allowable rate.

5. Patient Billing and Collections

A patient-friendly approach that maintains agency reputation while ensuring collections.

• Responsible Party Billing: We generate clear, easy-to-understand patient statements for balances due (co-pays, deductibles, non-covered services) after insurance processing.

• Customer Service: Dedicated patient service representatives handle all inquiries regarding bills, reducing the administrative burden on your staff and enhancing community relations.

• Hardship & Collection Management: Establishing and adhering to compliant policies for financial hardship applications and transferring severely delinquent accounts to ethical collections processes, as directed by your agency.

6. Facility and Affiliate Contract Billing

Facility and affiliate contract billing is a complex, distinct part of EMS RCM that involves managing pre-negotiated, non-insurance rates for high-volume services (like interfacility transfers) with partners such as hospitals and nursing homes.

• Contract Management & Rate Configuration:

  • Establishing and maintaining all unique, pre-negotiated contract rates (flat fees, tiered fees, add-ons) in the billing system.

  • Properly mapping Payer IDs and verifying the service scope covered under each official agreement.

• Precision Invoice Processing & Submission:

  • Auditing each transport against contract eligibility to ensure authorization requirements are met.

  • Applying the correct contractual adjustment and generating consolidated, periodic bulk invoices tailored to the facility’s specific submission format.

• Dedicated Accounts Receivable (A/R) & Compliance:

  • Conducting targeted A/R follow-up directly with the facility’s accounts payable department, bypassing standard patient finance channels.

  • Meticulously reconciling complex bulk payments back to individual patient claims.

  • Formally resolving payment discrepancies and disputes based on the specific language of the underlying contract.

Core EMS Billing Services: Financial Health from Dispatch to Deposit

Effective revenue cycle management (RCM) for Emergency Medical Services (EMS) requires deep expertise across clinical, regulatory, and financial domains. Our comprehensive billing services cover the entire lifecycle of a patient encounter to maximize clean claim submission, accelerate payments, and ensure full compliance.

Why Choose Us For Your EMS Billing Needs?

Choosing Responder Revenue Solutions, LLC means partnering with compliance-focused experts:

• One owner is a FF/EMT, the other dispatches, which means we speak your language.

• We can teach your staff to effectively QA.

• We are a small business, so you are always a priority and not just an account number.

• You can keep your CAD and ePCR (as long as your system can print NEMSIS files).

• Our owners have 20+ years of experience!

• Nothing is Outsourced...EVER! No more language barriers when your patients call to ask about an account statement.

• We are proudly based in Texas, but can help in any state.

• We believe in transparency with our clients. We don't hide stuff such as the status of accounts.

• Lastly, choosing us will free up your staff to focus on what they do best, and that is saving lives!