PS ITEM.5
April 26, 2010
Worksession
MEMORANDUM
TO:
FROM:
Public Safety Committee
~ichael
Faden, Senior Legislative Attorney
Minna Davidson, Legislative Analyst
'!!!1(:tY
SUBJECT:
Worksession: Expedited Bill 13-10, Emergency Medical Services Transport Fee
- Established
Expedited Bill 13-10, Emergency Medical Services Transport Fee - Established,
sponsored by the Council President at the request of the County Executive, was introduced on
March 23, 2010. A public hearing was held on Apri113.
Bill 13-10 would authorize the County to impose and collect a fee to recover costs
generated by providing emergency medical service transports. This bill would also provide for a
schedule of emergency medical services, transport fees, fee waiver criteria, permitted uses of fee
revenues and other procedures to operate the emergency medical services fee program. Bill 13­
10 would prohibit a local Fire and Rescue Department from imposing a separate emergency
medical services transport fee. The Executive would be required to issue regulations to
implement the fee; draft regulations are attached on ©9-11.
Fiscal analysis
County Executive's Budget Assumptions for FYll
For FYll, the Executive originally assumed $14.7 million in revenues from an EMS fee
as part of the MCFRS budget. He also assumed expenditures of $1.2 million to implement the
fee. The Executive's proposed implementation costs break out as follows.
Item
• Manager III
Information Technology Specialist II
Training of MCFRS personnel
Third party contractor
• Community
E~ucation
Total
$
wy
105,500
85,250
25,000
800,470
200,000
1,216,220
1.0
1.0
0.2
2.2
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After the Executive transmitted the FYll budget to the Council, he received updated
EMST fee revenue estimates which reduced the estimated FYll revenue to $14.1 million. On
April 22, the Executive proposed additional adjustments to the FYll operating budget which,
among other things, adjusted for a projected reduction of $557,000 in EMST fee revenues.
On the expenditure side, the Fiscal Impact Statement estimated a reduction of about
$30,000 in implementation costs because it may be possible to negotiate a more favorable third
party administrator contract.
Fiscal Impact Statement - Revised Revenues
The Fiscal Impact Statement (FIS) for this bill estimated that the EMST fee will result in
revenues of $14.1 million in FYll, $14.7 million in FY12, $15.2 million in FY13, and $15.8
million in FY14. These revenues have been adjusted downward from previous estimates that
were provided in November 2008. The total revenue estimate for the first 4-year period of
implementation has been reduced from $62.2 million to $59.8 million.
Comparison
of Estimated
EMT Fee Revenues (in millions)
Year 1
Year 2 Year 3 Year 4
Total
November 13, 2008 14.55
15.19
15.87
16.60 62.21
March 19,2101
14.14
59.76
14.66
15.20
15.76
Net Change
-0.41
-0.53
-2.45
-0.67
-0.84
The County requested the new estimates to consider any change in circumstances in
health care billing, as well as in the economic or political climate, which may have impacted
previous projections. In addition, the County began to use the new Electronic Patient Care
Reporting system (ePCR) in January, providing 2 months of actual data which were used to
replace previous assumptions that were based on informed estimates.
The Executive Summary in the attached
Updated 2010 EMS Transport Revenue
Projections
from Page, Wolfberg
&
Wirth, LLC, (PWW) lists the following major reasons for
the revenue change in order of impact. They are described in more detail under "Methodology
and Assumptions" on ©18-22.
• MCFRS dispatch data show a lower-than-anticipated Advanced Life Support
(ALS) dispatch rate, resulting in fewer transports eligible for ALS reimbursement
under the ALS Assessment rule;
• MCFRS ePCR and dispatch data compelled revising the ALS vs. Basic Life
Support (BLS) transport ratio from 57:43 to 45:55.
• Medicare implemented a 0% Ambulance Inflation Factor (AIF) for 2010. While
future years' AIF are expected to be positive, uncertainty over counterbalancing
Medicare cuts under the federal health reform law conservatively led us to assume
a 0% inflationary adjustment in allowed charges in years 2-4 of these projections.
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• The Geographic Practice Cost Index (GPCI) (which is used by Medicare to
calculate ambulance fee schedule reimbursement rates) for Maryland Locality 01
was adjusted from 1.08 to 1.057 in 2009.
In addition, the limited ePCR data made available by the County also showed a higher volume of
Advanced Life Support - Level 2 (ALS2) transports than previously anticipated, though this had
a negligible (but slightly positive) impact on the projections.
Issue: Fewer than anticipated ALS dispatches:
PWW noted that previously they
assumed an ALSIBLS ratio of 57% ALS to 43% BLS. In the January and February 2010
MCFRS dispatch data, approximately 60% of all dispatches were categorized as BLS. PWW
noted that these data appeared to under-triage the reporting of ALS conditions at the time of
dispatch, compared with their experience in other jurisdictions. They revised the ratio to 45%
ALS to 55% BLS.
Under the 1
+
1 ALS deployment model, "Charlie"-level ALS patients are transported to
the hospital by BLS units. (See ©44, footnote #2.) This practice enables ALS providers to
remain available to respond to other more serious ALS calls.
• To what extent is the apparent under-reporting of ALS conditions at the time of
dispatch related to the practice of transporting certain ALS patients by BLS units?
• If
an EMST fee is imposed, would decisions about policies and practices in the field
consider or be driven by the impact on EMST fee revenues?
Self-pay Charges:
Because there has been considerable discussion about assumptions
regarding self-pay (uninsured) individuals, Council staff notes that the PWW projection assumes
that 28% of those billed would be self-pay. Of those, PWW assumes that 90% would be County
residents from whom no fee would be collected. Of the remaining 10% -- non-County residents
who would be billed -- they assume a collection rate of 30%. Even though self-payers are
assumed to make up 28% of the billing population, the amount projected to be collected from
this payer category is relatively small. The self-pay calculation for Year One is on ©28.
Medigap Coverage:
In the past there have been questions about whether the PWW
calculations assume Medigap coverage of Medicare co-payments. Council staff notes that
Medigap co-payments are included in the Medicare Payer Category, and are estimated at 52% of
the co-payment amount. The Medicare calculation for Year One, including Medigap receipts, is
on ©27.
Legislative issues
Fee structure
The FIS assumed the following fee structure for a range of levels of
service. The fee structure would be established by County regulation (see draft regulation on
©9-11). The service levels (but not the fee amounts) are defined by Federal regulation.
3
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·
Type of Service
Transport mileage
Basic Life Support Non Emergency
Basic Life Support - Emergency
Advanced Life Support - Levell - Non-Emergency
Advanced Life Support - Level I - Emergency
Advanced Life Support - Level 2
Specialty Care Transport
*The PWW analysIs assumed $8.00 per mIle.
Fee
$8.50 per mile*
$300.00
$400.00
$$350.00
$500.00
$700.00
$800.00
In its fiscal analysis, PWW advised that the County's charges should be a fair amount
higher than the prevailing Medicare-approved rates because, under federal law, Medicare pays
the lesser of the approved Medicare fee schedule amount or the provider's actual charge. If a
provider charges less than the Medicare approved rate, Medicare only pays the provider's
charge, and does not pay the full scheduled amount.
The Executive's proposed fee structure
would set the EMST fees above the 2010 approved Medicare charges.
Council staff understands that because the Executive recommended an "insurance only"
collection model, raising the fees at this time would not produce much additional revenue. Since
the County will cover with taxes the portion of residents' EMST fees that are not paid by an
insurer, and will cover the entire fee for residents who are uninsured, a fee increase would only
affect co-payments and deductibles from non-County residents, and payment in full from the
small percentage of non-County self-payers who would pay the fee.
Waivers
As introduced, Bill 13-10 would require the Fire Chief to waive the EMST fee
for any individual whose household income is at or below 300% of the federal poverty
guidelines. Under the current guidelines (©42) a family of 4 would be eligible for a waiver if
their income is at or below $66,150.
County residents, whether insured or uninsured, would not have to pay any EMST fee
that is not covered by insurance. Thus, hardship waivers would only be needed for non-County
residents.
Are the Federal poverty guidelines an appropriate threshold for hardship waivers
for people who work, visit, or pass through the County?
In general, there is a sense that the
Federal poverty guidelines are low. At the same time, however, the higher the threshold for a
hardship waiver, more people would become eligible for waivers and fewer fees would be
collected.
In other programs, income eligibility is based on multiples of the federal poverty
guideline. For example, the State children's health insurance program has a sliding scale based
on 200% and 250% of the federal poverty leveL The threshold for eligibility in the County's
children's health insurance program is 250%. The threshold for the County's cancer screening
program is 250%. The Thornton Commission's requirement for pre-K services for high need,
low income children is based on .a threshold of 185%. The Maryland Energy Assistance
Program (MEAP) and Rental Assistance programs use different standards. For a family of four,
the MEAP threshold amount is about 175% of the federal poverty guidelines; the Rental
4
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Assistance amount is about 230%. The standard used by Fairfax County for waiver of their EMS
transport fee is 300%.
Timing of Fee Implementation The revenue projections in the FIS assumed mid-year
implementation of the fee, with retroactive billing to the beginning of the fiscal year. (This
assumes that the Council would enact Bill 13-10 before June 30, 2010.) Federal regulations
allow a health care provider to bill retroactively to the effective date in the authorizing
legislation.
If
the Council agrees with this approach, the
bill
would have to be amended to
allow retroactive billing during the first year start-up period.
Direct Allocation to the LFRDs When the Executive proposed an EMST fee in the
FYIO budget, he recommended $750,000 for a direct allocation of fee revenues to the Local Fire
and Rescue Departments (LFRDs). Although the Executive had budgeted for a direct allocation,
neither the proposed bill nor the proposed implementing regulation addressed this issue.
For FYll, the Executive did not recommend funding for a direct allocation to the
LFRDs. Bill 13-10 and the draft implementation regulation do not address this issue. In
response to questions on the budget, MCFRS staff indicated that the Executive is open to
discussing options for sharing revenues with the LFRDs.
If
the Council wishes to include a direct allocation of EMST fee revenues to the
LFRDs, the Council would have to decide the amount of the allocation and the conditions
under which it would be provided. The Council would also have to include funds for the
direct allocation in the FYII operating budget.
Supplement vs. Supplant The proposed implementing legislation for the FYIO EMST
fee (Bill 25-08 as revised) said that, except for the transfer of funds to cover residents' unpaid
EMS transport costs, the revenues from the EMST fee must be used to supplement, and
must not supplant, existing expenditures for EMS and other related fire and rescue services
provided by MCFRS.
Bill 13-10 (see ©3-4, lines 52-58) provides:
(h)
Use of revenue.
Except for the transfer received from the General Fund under
subsection (e) and in the first fiscal year this fee is implemented, the revenues
collected from the emergency medical services transport fee must be used to
supplement, and must not supplant, existing expenditures for emergency medical
services and other related fire and rescue services provided by the Fire and
Rescue Service.
Council staff assumes that the Executive intends that the "supplement not supplant"
requirement would apply in
all but the first year
of implementation, but others have interpreted
this language to mean that it applies
only in the first year.
Executive staff should clarify the
meaning of this subsection.
The Executive's recommended FYII-16 Fiscal Plan for the Consolidated Fire Tax
District is attached on ©41. EMST fee revenues are included in the "Charges for Services" line
5
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together with some fire code enforcement fees. While the EMST fees are not broken out
separately, it appears that revenue from the EMST fee would supplant fire tax revenues in FYll.
The picture is not as clear for FYI2.
An
increase in 4-person staffing, new ambulances
for Kingsview and Milestone, and an increase for a recruit class are assumed, but the cost of
these new initiatives would total only $7.12 million, about half of the projected FY12 EMST fee
revenue of$14.66 million.
It
is not clear whether the fiscal situation in FY12 will allow funding
of the new services that are envisioned in the Fiscal Plan. In addition, we would argue that
funding for a recruit class should be treated as an ongoing cost of operating MCFRS and thus not
count as supplementing.
Council staff would pose the following questions regarding this issue:
1) What is the Executive's intent regarding the "supplement not supplant" requirement? Is
this language in Bill 13-10 intended to exempt fee revenue from this requirement only for
the first year, or in all years except the first year?
2) Since the fee was originally proposed to supplement the existing MCFRS budget, should
the law allow the "supplement not supplant" requirement to be disregarded even for one
year?
3) If the exemption is intended to apply in the first year only, is it realistic to assume that it
will be possible to use fee revenue only to supplement the existing budget in FY12 and
later years?
Fairfax County experience
At the public hearing, representatives of the Volunteer Fire
and Rescue Association submitted information (see ©45) arguing that ambulance service calls in
Fairfax County decreased as a percentage of population after that County imposed its similar fee.
However, the EMS Deputy Chief of the Fairfax County Fire and Rescue Department who
testified at the same hearing (see testimony, ©46-47) attributed this decrease to a flawed
reporting system, and concluded that Fairfax County's implementation of the fee was well
planned and successful.
This packet contains:
Expedited Bill 13-10
Legislative Request Report
Memo from County Executive
Draft regulation
Fiscal Impact Statement
FY11-16 Fiscal Plan, Fire Tax District
2009/2010
HHS Poverty Guidelines
Excerpt from
FIR
EMS Master Plan 2009 Update
Materials re Fairfax County experience
Circle
#
1
5
6
9
12
41
42
43
45
F:\LAW\BILLS\1013 EMT Fee\PS Memo.Doc
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Expedited Bill No.
13-10
Concerning: Emergency Medical Services
Transport Fee - Established
Revised: 3-22-10
Draft No. _1_
Introduced:
lVIarch 23, 2010
Expires:
September 23, 2011
Enacted: _ _ _ _ _ _ _ _ __
Executive: _ _ _ _ _ _ _ _ __
Effective: _ _ _ _ _ _ _ _ __
Sunset Date:
----U.N~on:.!.::e"___
_ _ _ _ __
Ch. _ _, Laws of Mont. Co. _ _ __
COUNTY COUNCIL
FOR MONTGOMERY COUNTY, MARYLAND
By: Council President at the Request ofthe County Executive
AN EXPEDITED ACT
to:
(1 )
authorize the County to impose and collect a fee to recover costs generated by
providing emergency medical service transports;
(2) provide for a schedule of emergency medical services transport fees, fee waiver
criteria, permitted uses of fee revenues, and other procedures to operate the
emergency medical services fee program;
(3) prohibit a Local Fire and Rescue Department from imposing a separate emergency
medical services transport fee;
(4)
require the Executive to issue certain reguiations to implement an emergency
medical services transport fee;
(5) require a certain annual transfer
be
made as payment of residents' uninsured portion
of the emergency medical services transport fee; and
(6) generally amend County law regarding the provision of emergency medical services;
By adding
Montgomery County Code
Chapter 21, Fire and Rescue Services
Section 21-23A. Emergency Medical Services Transport Fee
Boldface
Underlining
[Single boldface brackets]
Double underlining
[[Double boldface bracketsD
Heading or defined term.
Added to existing law by original bill.
Deletedfrom existing law by original bill.
Added by amendment.
Deletedfrom existing law or the bill by amendment.
Existing law unaffected by bill.
,. ,. ,.
The County Council for Montgomery County, Maryland approves the following Act:
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EXPEDITED BILL
No. 11-10
1
2
3
4
5
6
7
8
9
10
11
12
Sec.
1.
Section 21-23A is added as follows:
21-23A.
Emergency Medical Services Transport Fee.
W
Definitions.
In this Section the following tenns have the meanings indicated:
ill
Emergency medical services transport
means transportation
Qy
the Fire and Rescue Service of an individual
Qy
ambulance or
other Fire and Rescue Service vehicle used for a similar
purpose.
Emergency medical services transport
does not
include transportation of an individual under an agreement
between the County and
~
health care facility.
ill
Federal poverty guidelines
means the applicable health care
poverty guidelines published in the Federal Register or
otherwise issued
Qy
the federal Department of Health and
Human Services.
13
14
15
16
ill
(Q)
Fire and Rescue Service
includes each local fire and rescue
department.
17
18
19
Imposition gffee.
The County must impose
~
fee for any emergency
medical services transport provided
in
the County and, unless
prohibited
Qy
other law, outside the County under
agreement.
(£)
~
20
21
mutual aid
22
23
24
Liability fOr fee.
Subject to subsection (Q1 each individual who
receives an emergency medical services transport is responsible for
paying the emergency medical services transport fee.
@
25
26
27
Hardship waiver.
ill
The Fire Chief must waive the emergency medical servIces
transport fee for any individual whose household income is at or
F:\LAW\BILLS\1013 EMT Fee\BiII1.DOC
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EXPEDITED BILL
No. 13-10
28
29
30
31
32
33
below 300 percent of the federal poverty guidelines.
An
individual must request
~
waiver on
~
form approved
Qy
the Fire
Chief.
ill
The Fire Chief may deny
~
request for
~
waiver if an individual
who claims financial hardship under this Section does not
furnish all information required
Qy
the Fire Chief.
34
35
36
37
38
39
ill
Payment gf Residents' Uninsured Portion gf the Emergency Medical
Services Transport Fee.
ill
Tax revenues received
Qy
the County must be treated as
payment, on behalf of County residents, of the balance of each
resident's portion of the emergency medical services transport
fee that is not covered
Qy
the resident's insurance.
40
41
ill
The County Council must annually transfer from the General
Fund to the Consolidated Fire Tax District Fund an amount that
the Council estimates will not be covered
Qy
residents'
insurance as payment of all residents' uninsured portion of the
emergency medical services transport fee.
42
43
44
45
46
ill
Obligation to transport.
The Fire and Rescue Service must provide
emergency medical services transport in accordance with applicable
medical protocols to each individual without regard to the individual's
abi1ityto~
47
48
49
{g}
Restriction on Local Fire and Rescue Departments.
A local fire and
50
51
52
53
54
rescue department must not impose
medical transport.
~
separate fee for an emergency
.au
Use gf revenue.
Except for the transfer received from the General
Fund under subsection
ill
and in the first fiscal year this fee is
implemented, the revenues collected from the emergency medical
CD
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EXPEDITED BILL
No. 13-10
55
56
servIces transport fee must be used to supplement, and must not
supplant, existing expenditures for emergency medical services and
other related fire and rescue services provided
Qy
the Fire and Rescue
Service.
57
58
59
60
61
ill
Regulations; fee schedule.
The County Executive must adopt
!!
regulation under method
ill
to implement the emergency medical
services transport fee program. The regulation must establish
!!
fee
schedule based on the cost of providing emergency medical services
transport.
The fee schedule may include an annual automatic
62
63
64
65
66
67
adjustment based on inflation, as measured
Qy
an index reasonably
related to the cost of providing emergency medical services transports.
The regulation may require each individual who receives an
emergency
medical
servIces
transport
to
provide
financial
68
69
70
information, including the individual's Insurance coverage, and to
assign insurance benefits to the County.
Sec. 2.
Expedited Effective Date.
71
72
The Council declares that this legislation is necessary for the immediate
protection of the public interest. This Act takes effect on the date when it becomes
law.
Approved:
73
74
75
76
77
Nancy Floreen, President, County Council
Date
78
79
80
Approved:
81
Isiah Leggett, County Executive
Date
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LEGISLATIVE REQUEST REPORT
Expedited Bill 13-10
Emergency Medical Services Transport Fee - Established
DESCRIPTION:
This Bil1 would authorize the County to impose and collect a fee to
recover costs generated by providing emergency medical services
transports.
In order to meet current fiscal challenges facing the County, the County
must increase the amount of revenue available to maintain core
Government programs and services.
To enhance the amount of revenue available to support core government
programs and services.
PROBLEM:
GOALS
AND
OBJECTIVES:
COORDINATION:
Office of Management and Budget; Department of Finance; Fire and
Rescue Service
FISCAL IMPACT:
To be requested.
ECONOMIC
IMPACT:
EVALUATION:
To be requested.
Subject to the general oversight of the County Executive and the County
Council.
Many jurisdictions in the regions have imposed an emergency
medical services transport fee.
Joseph Beach, Director of Management and Budget
Kathleen Boucher, Assistant Chief Administrative Officer
Richard Bowers, Chief, Fire
&
Rescue Service
Marc Hansen, Acting County Attorney
EXPERIENCE
ELSEWHERE:
SOURCES OF
INFORMATION:
APPLICATION
Yes.
WITHIN
MUNICIPALITIES:
PENALTIES:
To be researched.
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OFFTCE OF THE COUNTY EXECUTIVE
ROCKVILLE, MARYLAND 20850
lsiah Leggett
Coun(v
Executive
MEMORANDUM
March 18, 2010
\
TO:
FROM:
SUBJECT:
Nancy Floreen, Council President
Isiah Leggett, County
EXe£utive~~~
,/'-"'}
FY 2011 Budget Reconciliation and Financing Act
I am attaching for Council's consideration a Budget Reconciliation and Financing
Act (BRF A) which makes changes to the County Code that are necessary to reconcile my
recommended FY 2011 operating budget with projected FY 2011 revenues. This bill will help
the County address its current fiscal challenges by increasing the amount of revenue available to
maintain and enhance core government programs and services. I am also attaching a Legislative
Request Report for the bill. A Fiscal Impact Statement will be transmitted to Council soon.
The BRFA consists of five primary components. First,
it
increases the energy tax
rates. Second, it temporarily redirects the portion of recordation tax revenues that are currently
reserved for County Government capital projects and rental assistance programs to the general
fund for general purposes. Third, it allows revenues generated by the Water Quality Protection
Charge to be used to pay debt service on bonds that fund stormwater management infrastructure
projects. Fourth, it transfers responsibility for administering equal employment opportunity
programs from the Office of Human Resources to the Office of Human Rights. Fifth,
it
authorizes the Fire and Rescue Service to impose an Emergency Medical Services (EMS)
Transport Fee.
As the Council knows, the County's energy tax is actually a tax on fuel oil,
natural gas, and electric utility providers which is passed on to all utility customers. Because the
energy tax is a broad-based tax, its impact on families is reduced by the fact that it is paid by
businesses and households, and all levels of govemment, including federal agencies located in
the County (that currently do not pay any other major County tax). Additionally, the energy tax
is a consumption tax based on energy usage.
It
is not based on the overall size of the utility bill
or the cost per unit of energy used as billed to the consumer. Therefore, the amount of the tax
can be lessened by reduced energy usage. Based on existing usage patterns for the average
homeowner, my recommended FY 2011 budget assumes an average increase in the energy tax of
approximately $2.90 per month. I have also recommended additional funding in the Health and
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Nancy Floreen, Council President
March 18,2010
Page 2
Human Services budget for the County's Energy Assistance Program to minimize the impact to
low-income households.
My recommended FY 11 budget contains several efforts to restructure County
Government to improve responsiveness and efficiency. One of these changes is the transfer of
the Equal Employment Opportunity program from the Office of Human Resources to the Office
of Human Rights. This shift takes advantage of existing staff resources to reduce costs and
leverage the efforts of County staff to produce better outcomes for the community. This bill
modifies the County code provisions relating to the responsibilities of the Office of Human
Resources and Office of Human Rights to reflect this change.
The EMS Transport Fee is needed to fund fire and rescue services in the County.
Without this fee, emergency response to residents will be impaired. EMS Transport Fees are
widely employed throughout the nation and by local governments throughout the Washington
region. These jurisdictions have not experienced any indication that people decline to use
emergency transports as a result of the imposition of an ambulance fee. By creating a prepaid
fund for uninsured County residents, the legislation that I am transmitting imposes a fee only on
County residents with health insurance which covers EMS Transports. This arrangement more
equitably distributes the economic burden of providing EMS transport services in the County
between residents and nonresidents. The legislation provides for a hardship waiver for
nonresidents who fall below 300 percent of federal povCliy guidelines.
To provide the Council with a complete picture of the EMS Transport Fee
program created by this bill, I am attaching a copy of the proposed Executive Regulation to
implement the fee. This proposed regulation will be published in the Apri12010 County Register
and submitted to Council after the 30-day public comment period ends on April 30.
Finally, I note that the BRFA is consistent with Bill 31-09, Consideration of
Bills One Subject (Cllacted on September 29,2009), which requires that a bill "contain only
one subject matter".' As noted in the Council staff packet for Bill 31-09, that bill was intended to
adopt the "one subject rule" of the Maryland Constitution, which requires all laws enacted by the
General Assembly to contain only one subject. The Maryland Attorney General has repeatedly
concluded that budget reconciliation and financing bills do not conflict with the one subject rule.
For example, in 2005, the Attorney General noted that "[f]or the past fourteen years, 15 budget
reconciliation, budget reconciliation and financing acts or variations thereof, have been used to
balance budgets, raise revenue, make fund transfers, redistribute funds, cut mandated
appropriations and authorize or mandate appropriations."! The Attorney General concluded that
all of those bills were consistent with the one subject rule because the provisions of the bills were
"clearly germane to the single subject of financing State and local government".
See Panitz
v.
Comptroller a/the Treasury,
247 Md. 501 (1967) (Omnibus supplemental appropriation bill
comprised a single subject for purposes of
§
29 of
Art
III of the State Constitution even though
I
See May 19, 2005 memorandum from Attorney General J. Joseph Curran, Jr. to Governor Robert Ehrlich regarding
House Bill 147 (2005).
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Nancy Floreen, Council President
March 18,2010
Page 3
the bill combined such diverse elements as police aid to local government; teacher salaries and
pensions; and general unrestricted grants to local government).
Attachments (3)
cc:
Joseph Adler, Director, Office of Human Resources
Jennifer Barrett, Director, Finance Department
Joseph Beach, Director, OMB
Kathleen Boucher, ACAO
Richard Bowers, Fire Chief, MCFRS
Marc Hansen, Acting County Attorney
Robert Hoyt, Director, DEP
Richard Y. Nelson, Jr., Director, DHCA
James Stowe, Director, Office of Human Rights
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MONTGOMERY COUNTY
EXECUTIVE REGULATION
Offices
of the
County Executive -101 Monroe Street· Rockville, Maryland 20850
Number
Subject
Emergency Medical Service Transport Fees
Originating Department
Montgomery County Fire and Rescue Service
Montgomery County Regulation on
Effective Date
EMERGENCY MEDICAL SERVICE TRANSPORT FEES
Issued by: County Executive
Regulation No.
COMCOR: Chapter 21
Authority: Code Section 21-23A
Supersedes:
NI
A
Council Review: Method (2) under Code Section 2A-I5
Register Vol. __ No. _ _
Effective Date: Date Bill XX-I0, "FY
2011
Budget Reconciliation and Financing Act"
becomes effective
Comment Deadline: April 16, 2010
Summary:
This Regulation establishes: (1) An emergency medical services transport fee schedule;
and (2) a requirement that an individual who receives an emergency medical services
transport provide certain information and execute an assignment of certain health
insurance benefits.
Scott Graham, Assistant Chief, Montgomery County Fire and Rescue Service
(240) 777-2493
Montgomery County Fire and Rescue Service
101 Monroe Street, 12th Floor
Rockville, Maryland 20850
Staff contact:
Address:
Page I of3
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MONTGOMERY COUNTY
EXECUTIVE REGULATION
Offices of the County Executive
101
Monroe Street • Rockville, Maryland 20850
Subject
Emergency Medical Service Transport Fees
Originating Department
Montgomery County Fire and Rescue Service
Section 1.
Fee Schedule
a.
In imposing and collecting the emergency medical services transport fee authorized under
Code Section 21-23A, the Fire Chief must comply with all applicable provisions of
42 CFR Parts 410 and 414,
Fee Schedule for payment ofAmbulance Services and
Revisions to the Physician Certification Requirements for Coverage ofNon-emergency
Ambulance Services.
The Fire Chief must impose the emergency medical services transport fee according to
the following schedule:
1.
Number
Effective Date
b.
11.
$8.50 per mile, one way, from point of pick up to
the health care facility; plus
• Basic Life Support Non-emergency*
• Basic Life Support Emergency*
• Advanced Life Support - Levell - Non-Emergency*
• Advanced Life Support - Levell - Emergency*
• Advance Life Support - Level 2*
• Specialty Care Transport*
$300.00
$400.00
$350.00
$500.00
$700.00
$800.00
* The terms in the schedule are as defined in 42 CFR Parts 410 and 414.
Section 2.
Required Information; Assignment of Benefits.
a.
An individual who receives an emergency medical services transport must furnish
to the County or the County's designated agent: (i) information pertaining to the
individual's health insurer (or other applicable insurer); and (ii) if applicable, financial
information that the Fire Chief determines is necessary for determining eligibility for a
waiver of the fee.
An insured individual who receives an emergency medical services transport must
execute an assignment of benefits necessary to permit the County to submit a claim for
the fee to the applicable third party payor.
The Fire Chief must increase the amount of the fees in the schedule annually by the
amount of the Ambulance Inflation Factor (AIF) as published by the Centers for
Medicare and Medicaid Services (CMS), United States Department of Health and Human
Page 2 of3
b.
c.
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MONTGOMERY COUNTY
EXECUTIVE REGULATION
Offices of the County Executive • 101 Monroe Street • Rockville, Maryland 208S0
Subject
Emergency Medical Service Transport Fees
Originating Department
Montgomery County Fire and Rescue Service
Services.
Number
Effective Date
Section 3.
Severability.
If a court of final appeal holds that any part of this regulation is invalid, that ruling does not
affect the validity of other parts of the regulation.
Section 4.
Effective Date.
This regulation is effective on the date that
Bill
XX-lO, "FY
2011
Budget Reconciliation and
Financing Act" becomes effective.
Approved:
Isiah Leggett, County Executive
Page 3 of3
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OFFICE OF MANAGEMENT AND BUDGET
Isiah Leggett
County Executive
Joseph F. Beach
Director
MEMORANDUM
April 8, 2010
TO:
FROM:
SUBJECT:
Nancy Floreen, President, County Council
_
JOSephF.Beaob.D~
Expedited Bill 13-10, Emergency Medical Service Transportation Fee - Established
~~
The purpose of this memorandum
is
to transmit
a
fiscal and economic impact
state~t
to
the Council on the subject legislation.
'-0
LEGISLATION SUMMARY
"
The expedited bill proposes the following: authorize the County to impose and collect a
fee to recover costs generated by providing emergency medical service transports; provide for
a
schedule
of emergency medical services transport fees, fee waiver criteria, permitted uses offee revenues, and
other procedures
to
operate the emergency medical services fee program; prohibit a Local Fire and
Rescue Department from imposing a separate emergency medical services transport fee; require tbe
Executive
to
issue certain regulations
to
implement an emergency medical services transport fee; require a
certain
annual transfer be made as payment ofresidents' uninsured portion ofthe emergency medical
services transport fee; and generally amend County law regarding the provision of emergency medical
services.
FISCAL SUMMARY
Revenues
The
projected revenues
are
based
on a
mix offour payer types: Medicare, Medicaid,
Commercial!Auto Insurance and Self Pay and average revenue per transport rate of$248 in FYI I down
to $246
in
FY14 and a Montgomery County Fire and Rescue Service estimated transport volume of
56,911 for
FYI1
which
is
expected to increase to 64,091
in
FY14.
The legislation
is
expected to resuH in revenues of $14.1 million
in
FY111 • $14.7 million
in
FY12. $15.2 million in FY13, and $15.8 million
in
FY14. The
FYI I
revenue of$14.1 million is a
decrease from the County Executive's recommended
FYl1
operating budget revenue assumption of $14.7
million due to updated revenue projections that reflect the following factors: available ePCR data (since
Januazy
2010) and updated dispatch data; Medicare implementing
a
0010
inflation factor
in
2010, down
from
5% in 2009 (due to uncertainty for the federal health care reform); and the lowering ofthe
Assuming
mid-year implementation,
with
collection ofrevenues beginning retroactively
:from
the beginning of the
fiscal
year
assuming
COlmeil
passage
ofthe expedited legislation
before June 30,2010.
I
---------------_
Office of the Director
..._ - . . . .
101 Monroe Street, 14th Floor • Rockville, Maryland 20850 • 240-777-2800
www.montgomerycountymd.gov
------------------­
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Nancy Floreen, President, County Council
April
8,2010
Page 2
Geographic Practice Cost index from
1.08
to
1.057
(used by Medicare to calculate ambulance fee
schedule reimbursement rates). For additional details on the basis of these estimates please see the
attached EMS Transport Revenue Projections Report prepared for the County by Page, Wolfberg, and
Wirth.
Expenditures
Personnel Costs
It
is
expected that
in
the first year of implementation two additional fun·time personnel
wiII
be needed for implementation: a Manager of BiI1ing Services and an Information Technology
Specialist The
FYI 1
salary, wages and benefits total will
be
$190,750.
Operating Expenses
Operating expenses for FYI
I
are comprised of third party contract expenditures of
$770,87<r (5.5% of gross revenues collected), $200,000 fOT community outreach activities, and
$25,000
for training. Total annual operating expenses for full year operation ofthe program are dependent, in
part,
on the negotiated fee fOT the third party contractor who will manage the bi1ling program on behalf of
the County. Also, the costs ofcommunity outreach will
be
reduced after the initial year of
implementation because the need for these outreach activities will not
be
as significant when the program
is fully operational.
ECOMONIC
SUMMARY
Since the EMS Transport Fee is employed by local governments throughout the
Washington region, it is most likely that the imposition ofthe fee will have no economic impact on the
County.
The following contributed to and concurred with
this
analysis: Blaise DeFazio, Office of
Management and Budget; Scott
Graham,
Montgomery County Fire and Rescue Service;
Dominic Del Pozzo, Montgomery County Fire and Rescue Service; Michael Coveyou, Department of
Finance; and David Platt, Department ofFinance.
JFB:bdf
Attachment
c: Timothy
L.
Firestine, Chief Administrative Officer
Richard Bowers, Chief: Montgomery County Fire and Rescue Service
Kathleen Boucher, Assistant Chief Ad.ministra:tive Officer
Jennifer Barrett, Director, Department ofFinance
Marc
Hansen, Acting County Attorney, Office of the County Attorney
David Dise, Director, Department ofGeneral Services
Scott
Graham,
Montgomery County Fire and Rescue Service
Alexandre Espinosa, Office ofManagement and Budget
Dominic Del Pozzo. Montgomery County Fire and Rescue Service
John Cuff, Office of Management and Budget
Blaise DeFazio, Office ofManagement and Budget
The Executive's March 15
th
recommended operating budget assumed
third
party
contract expenditures of$800,470
or 5.5% of$14.7 million
in
gross revenues collected. The contractor cost
may
be revised
based on a
more
favorable
2
contract arrangement
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PRIVILEGED AND CONFIDENTIAL
ATTORNEY-CLIENT COMMUNICATION
MONTGOMERY COUNTY FIRE RESCUE SERVICES
Updated 2010 EMS Transport Revenue
Projecti.ons
Submitted
By:
The National EMS Industry
Law
Firm'''
March 19, 2010
Page, Wolfberg
8.
Wirth, LLC
5010
E.
Trindle Road, Suite 202
Mechanicsburg, PA 17050
(717) 691"()100
(717) 691-1226
(fax)
Web Site: www.pwwemslaw.com
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EXECUTIVE SUMMARY
If EMS insurance billing is implemented in Montgomery County, Maryland, the
County is projected to generate $59,776,918 in new revenue over the initial four years of the
program. Thereafter, the County would be expected to continue to derive in excess of $15
million per year of new revenue under the program. Under the proposed Montgomery
County EMS transport fee model, none ofthe projected revenues would paid out of the
pockets of County residents.
This report supplements two earlier reports, submitted in January and November of
2008. The County requested this updated report in light of any changed circumstances in
health care billing, as well as the economic and federal political climate, that may have
impacted our earlier projections. In addition, in January, 2010 the County transitioned its
EMS operations from paper-based to electronic patient care reporting, so a limited amount
of actual data became available to replace assumptions that could only previously be made
Using informed estimates.
The updated 2010 report adjusts the total four-year revenue projections downward
by $2,454,584 (from $62,231,502 to $59,776,918) as compared to the four-year projections
in the November, 2008 report. The major reasons (none of which were foreseeable at the
time of the 2008 projections) for this change, in order of impact, are:
• MCFRS dispatch data show a lower-than-anticipated Advanced Life
Support (ALS) dispatch rate, resulting in fewer transports being
eligible for ALS reimbursement under the ALS Assessment rule;
• MCFRS ePCR and dispatch data compelled revising the ALS vs.
Basic Life Support (BLS) transport ratio from 57:43 to 45:55.
• Medicare implemented a 0% Ambulance Inflation Factor (AIF) for
2010. While future years' AIF are expected to be positive, uncertainty
over counterbalancing Medicare cuts under the pending federal health
care reform legislation have conservatively led us to assume a 0%
inflationary adjustment in allowed charges in years 2-4 of these
projections; and
• The Geographic Practice Cost Index (GPCI) (which is used by
Medicare to calculate ambulance fee schedule reimbursement rates)
for Maryland Locality 01 was adjusted from 1.08 to 1.057 in 2009.
In addition, the limited ePCR data made available by the County also showed a
higher volume of Advanced Life Support - Level 2 (ALS2) transports than previously
antiCipated, though this had a negligible (but slightly positive) impact on the projections.
Montgomery County, Maryland
Updated 2010 EMS Transport Revenue Projections (March 19,2010)
Page 2
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TABLE OF CONTENTS
Executive Summary.......................................................................................... 2
I.
II.
Overview..................... .. . .......... . ....... .. ....................................... ......... .... 4
Methodology and Assumptions........ ................................ ..... ........ ............. 5
A.
B.
C.
D.
E.
Time Intervals ........................,...................................................... 5
Estimated Transport Volume ............................................................ 5
Transport Mix by Payor ................................................................... 5
Transport Mix by level of Service..................................................... 6
Payor Type ................................................................................... 7
Self-Pay Transports ..........................................................: ............ 7
Mileage....................................................................................... 7
Charges..........................................· ........................................... 7
.
Approved Charges ........................................................................ 8
"Allowables"................................................................................. 9
Patient Care Documentation ............................................••.•............ 9
F.
G.
H.
I.
J.
K.
III.
Revenue Projections................................................................................ 10
A.
B.
Total Cash Receipts ....................................................................... 10
Average Revenue Per Transport ...................................................... 10
Gross and Net Collection Percentages .............................................. 10
C.
IV.
V.
Conclusion......................... ...... . ... ................................ .... .................... 12
Important Notices................................................................................... 12
Appendix A - Year One Revenue Projections......... ..... .......................................... 13
Appendix B
Year Two Revenue Projections........................................................ 16
Appendix C - Year Three Revenue Projections ................................
~.....................
19
Appendix D - Year Four Revenue Projections ........................................................ 22
..Appendix E - EMS Rate Setting Article .................................................................. 25
Montgomery County, Maryland
Updated 2010 EMS Transport Revenue Projections (March 19,2010)
Page 3
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L Overview
Montgomery County Fire Rescue Services (MCFRS) is evaluating the potential
implementation of an EMS Transport Revenue Recovery Program. MCFRS has engaged
Page, Wolfberg
&
Wirth, LLC (PWW), a national EMS industry law and consulting firm, to
assist it in this process. Among the tasks with which PWW is charged is the development of
revenue projections that might be realized In the event that the revenue recovery program is
implemented. PWW was asked to update these projections in March, 2010. At that time,
some of the first electronic patient care reporting (ePCR) data became available, with the
system having been implemented countywide in January,'2010. We have stated in this
updated report where assumptions were changed based on these data, though
it
must be
noted that two months of data might not be representative of EMS trends in the County.
Nevertheless, where actual data are now available to replace prior assumptions in certain
aspects of the projections, the data will
be
used instead of the assumptions.
When assessing potential revenues from any proposed health care billing
undertaking,
it
must
be
remembered that revenue forecasting is both an art and a science;
there is little in the way of published, pUblicly-accessible data from which meaningful
comparisons to similar jurisdictions can be drawn. Whenever possible, key assumptions
affecting these projections were kept on the "conservative" side, and many such
assumptions are based on our experience in working with EMS systems of all configurations
across the United States. All assumptions made in the generation of these projections will
be stated so that Montgomery County elected officials, policymakers and Fire Rescue
leadership can be guided accordingly.
Our detailed revenue projection spreadsheets for Years One - Four are attached to
this report as Appendices A-D.
Previous revenue projection reports dated January
18,
2008 and November
13,
2008
were also provided to the County. .
Montgomery
County,
Maryland
Updated 2010 EMS Transport
Revenue
Projections (March
19,
2010)
Page 4
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Il. Methodology and Assumptions
A.
Time Intervals
This report provides four
(4)
years of revenue projections. We utilized
2010
Medicare rates as a starting figure for this updated report. The reports are presented on a
Calendar Year (CY) basis. These projections were made on a CY basis primarily because
Medicare (from which the single largest portion of revenues is expected to be derived)
typically adjusts its allowed rates on a calendar year basis. CY projections can easily be
converted into Fiscal Year (FY) projections by taking a pro-rata share of the annual
projections and combining them with the corresponding pro-rata portion of the subsequent
.calendar year's projections.
I
B.
Estimated Transport Volume
All estimated transport volumes utilized in this report were provided by MCFRS. This
statistic is the key driver in any EMS transport fee revenue projection model. We note that
MCFRS previously utilized a paper patient care reporting approach, which limits both the
accuracy and the quantity of available data from which these projections can be made.
Starting in January,
2010,
the County transitioned to an electronic patient care
reporting system (ePCR). For the purpose of preparing this updated
2010
report, two
. months of
201 0
data was made available to
PWW
for review (January and February
2010).
Although caution should be taken In generalizing a mere two months of ePCR data
(particularly in months where two of the worst weather-related events of the past
25
years hit
the region), the data generally confirm the transport volume estimations made by PWW in
the
2008
reports. For instance, the estimated ALS1-Emergency transport volume in Year
two of the November
2008
PWW report was
12,535,
or an average of
1044.58
transports
per month. According to the MCFRS ePCR data for January,
2010.
the reported number of
ALS transports in January,
2010
was
1029,
a variation of less than
1.5%.
Therefore, the
total transport volume estimates have not been modified in this report.
Modest annual increases in call volume, which can be. expected as population grows,
continue to be assumed in these updated
2010
projections, as they were in the
2008
reports.
C.
Transport Mix by Payor
Transport mix estimates are found on the top of each spreadsheet (Exhibits A-D).
The "transport mix" is the number and percentage of transports by applicable payor type.
Because MCFRS has not previously billed for EMS transport, these payor mix
percentages are estimates which are, if anything. designed to conservatively underestimate
revenues. It is possible that in actual experience, the ·Self Pay" category (which includes
uninsured patients and patients for whom insurance cannot be identified) will be lower than
the estimated
28%.
In addition, the possible enactment offederal health care reform
legislation might ultimately reduce the Self Pay category by moving more of the uninsured
into an insured category. Lowering the Self Pay category would move more people into
either the Commercial Insured, Medicare or Medicaid categories; which would have a
resulting increase on revenues. However, we believe
it
is best to continue to estimate the
Montgomery County, Maryland
Updated 2010
EMS Transport Revenue Projections (March 19,
2010)
Page 5
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payor mix more conservatively and therefore will continue to use the previous payor mix
estimates.
D.
Transport Mix by Level of Service
Within each payor category, we utilized a consistently estimated approach to the
level of service mix (Le., BLS vs. ALS). In our 2008 report, we utilized an Al5-BLS ratio of
57143
(i.e., 57% ALS, 43% BLS). In the two months of 2010 dispatch data provided by the
County, we note that approximately 60% of all dispatches were categorized as BLS (59.3%
in January, 2010 and 60.3% in February, 2010). These data appear to under-triage the
reporting of ALS conditions at the time of dispatch when compared to our experience in
other jurisdictions. The 57/43 projections used in the 2008 report were conservative based
on our experience in other jUrisdictions, and frankly we were surprised to see such a low
percentage of ALS dispatches in the January and February 2010 data.
Medicare rules reimburse ambulance services at the ALS1-Emergency level for
medically necessary, covered transports when the provider furnishes a qualifying "ALS
Assessment,· even if no ALS interventions are provided. However, a prerequisite to billing
for ALS Assessments is a qualifying ALS-Jevel dispatch. Because MCFRS data suggest
under-triage of ALS dispatch conditions, we are revising the ALSIBLS ratio to 45/55. We
are selecting 45/55 because, even though the reported percentage of ALS-Ievel dispatches
are only 40%, there will undoubtedly be a number of calls where the reported dispatch is
condition is BLS but the patient is found to require an ALS intervention. The revision of
these service mix estimates will have a negative effect on the revenue projections, though
that will of course make the projections even more conservative.
Certainly as more ePCR and CAD data become available, these service mix
estimates can be revisited.
It is also important to note that we assigned a small (almost negligible) percentage
(1 %) of transports to "non-emergency" levels of service. We recognize that MCFRS is solely
a 911, emergency provider. However, until dispatch protocols are fully integrated with billing
systems, there is a chance that on a small percentage of calls, billers will not have the
requisite emergency dispatch information available to them and, acting out of an abundance
of compliance, will code the claims as "non-emergencies." That is why non-emergency
levels of service are included in the model.
We also included the "SpeCialty Care Transport" (SCT) level of service on the
spreadsheet model, though we did not assign any transports to this category. SCTs are
interfacility transports, which we presume would not be handled by MCFRS, though the SCT
category is included in case MCFRS would like to investigate the financial impact of
providing this type of service in the future.
In our 2008 reports we also assumed a relatively conservative 1% for "ALS2" level
transports. This is a more intensive (and higher-reimbursed) level of service that applies
when a patient receives invasive interventions such as endotracheal intubation. We note
that the January/February 2010 ePCR data reported by MCFRS suggest that the actual
AlS2 percentage might be as high as 2.1
%.
Accordingly, we have adjusted our ALS2
service mix from 1
%
to 2%. A small positive impact on revenues will result from this
change.
Montgomery County, Maryland
Updated 2010 EMS Transport Revenue Projections (March 19, 2010)
Page 6
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E.
Payor Type
There are four payor types utilized in these projections: Medicare, Medicaid,
Commercial/Auto Insurance and Self-Pay. As a provider of emergency, 911 services only,
. we assumed that MCFRS will not enter into contracts with Medicare managed care
("Medicare Advantage") organizations or other commercial payors. Therefore, because non­
contracted providers are paid by Medicare Advantage plans for emergency transports at the
Medicare fee-for-service rates, all transports of Medicare Advantage patients are included in
the "Medicare" category. "Medigap" copayments are also included in the Medicare
category, with an estimate of 52% of copayments being paid by these Medicare
supplemental insurance policies ("Medigap"). Similarly, the "Commercial/Auto Insurance"
category includes commercial managed care plans, traditional indemnity "fee-for-service" ,
plans. automobile liability insurance policies, workers compensation payments, and similar
types of commercial or self-insurance.
F.
Self-Pay Transports
In this model, we assumed that the County would implement an "insurance only"
billing policy, under which County residents would be billed only to the extent of available
insurance. County residents would not be billed for copayments, deductibles or other
charges unmet by their insurance coverage (in addition, no payment would be collected
from uninsured residents). We assume that 90% of patients in the Self Pay category will be
County residents, and, therefore that only 10% of the Self Pay category are non-residents.
We further also assume a collection rate of 30% from the non-resident, self-pay population
in this model.
G.
Mileage
Medicare and most commercial payors reimburse ambulance services for "loaded"
miles, i.e., for those miles which the patient is on board the ambulance, from the point
of
pickup to the closest appropriate destination. We made the assumption, given the
geography, population centers and population density of the County, that the average
transport would include five
(5)
loaded miles.
As
with all assumptions in this model, this
particular assumption can be modified to determine the resulting impact on revenues if
desired.
H.
Charges
We included a proposed schedule of charges for each level of service. Of course,
the selection of a rate schedule is entirely up to County policymakers and is typically a factor
of many economic and political considerations. However, the County's charges
should~
without question, be a fair amount higher than the prevailing Medicare-approved rates,
because, under Federal law, Medicare pays the
lesser
of the approved Medicare fee
schedule amount orthe provider's actual charges. In other words, if a provider charges less
than the applicable Medicare fee schedUle payment, Medicare does not "make up the
difference."
It
becomes legitimate revenue that is irretrievably lost and cannot be recovered
from any other source. Establishing rates that are comfortably above the approved
Medicare fee schedule amounts is a paramount consideration in the establishment of any
ambulance rate schedule.
Montgomery
County, Maryland
Updated 2010 EMS Transport Revenue Projections (March 19.2010)
Page 7
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'.'
We assumed an annual increase of 5% in the County's ambulance rate schedule
(i.e., charges) in years 2-4.
An article dealing with ambulance rate-setting that the County might find helpful is
attached to this report as Appendix E.
I.
Approved Charges
For each payor category (except, of course, for self-pay), we estimated an "approved
charge." This is the amount that Medicare, Medicaid or commercial insurers will approve for
the particular level of service. Medicare rates are established annually according to a
national fee schedule and vary slightly based on geography (due to the incorporation ofthe
"Geographic Practice Cost Indicator" (GPCI) from the Medicare physician fee schedule into
the Medicare ambulance fee schedule. The 2008 projections assumed a GPCI of 1.08,
which was at that time the applicable GPCI for Maryland locality 01. For purposes of this
2010 updated report, we note that the Medicare approved charges reflect a GPCI for
Maryland locality 01 that was slightly adjusted in 2009 by Medicare to 1.057. This will have
a negligible, though slightly negative effect on the projections.
We also note that in our 2008 report, we used 2008 approved Medicare charges as
the "starting point" upon which all subsequent years' projections were based. For purposes
of this updated 2010 report, yve are using 2010 approved Medicare charges as the starting
point, which are approximately 3.4% higher than they were in 2008.
With regard to the GPCI, a portion of the Medicare' Ambulance Fee Schedule is
adjusted to reflect geographic cost differences in providing ambulance services in different
parts of the country. Because Medicare found
it
inefficient to develop a national cost index
specific to measure the different costs of providing ambulance services across the United
States, it simply "borrowed" a geographic cost formula it had already developed for the
Physician Fee Schedule and incorporated into the Ambulance Fee Schedule. That formula
is the "Practice Expense" portion of the Geographic Practice Cost Index (GPCI),from the
PhysiCian Fee Schedule.
Medicare rates have historically increased annually by a modest inflation factor. In
2007, Medicare announced an Ambulance Inflation Factor (AIF) of 2.7% for dates of service
in CY 2008. A 5% AIF was adopted for dates of service in CY 2009. Since the adoption of
the Medicare ambulance fee schedule in 2002, there has consistently been a positive AIF.
Therefore. we conservatively assumed a 2.5% Medicare AIF for years 2-4 of the projections
in our 2008 report. However, since the AIF is based on a consumer price index, and
because of deterioration in the overall economy, Medicare adopted a 0% AIF for 2010. In
addition, as of December 31, 2010, some temporary Medicare ambulance increases expired
and were not legislatively renewed. Finally, the pending health care refonn legislation
WOUld, if enacted, result in Medicare cuts over
th~
next several years, though ambulance
reductions are not specificafly targeted. Nevertheless, we are modifying our projections to
presume a 0'% AIF in years 2-4. We do not belieVe it to be likely that there will be continued
0% growth in approved charges, but in order to keep these projections as conservative as
possible, we are assuming 0% inflation In the 2010 base rates for years 2-4 for the Medicare
and Commercial categories.
As
in our 2008 reports, we assumed no annual increase in
Maryland Medicaid rates, which are a flat $100 (AlS or BLS) with no allowance for loaded'
mileage.
.
Montgomery County, Maryland
Updated 2010 EMS Transport Revenue Projections (March 19, 2010)
Page 8
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For commercial insurers, we assumed an overall percentage of approved charges of
67%. It is very difficult to predict with certainty how this payor class will respond to the
implementation of an EMS billing program. Some commercial insurers pay 100% of billed
charges for emergencies without question; others take aggressive stands against paying full
charges and often will pay some arbitrary amount that they deem to be "reasonable." We
believe that an overall figure of 67% of charges takes these variables into account.
The difference between MCFRS's charges and the payor-"approved charges" are
ordinarily not collectible. With regard to Medicare, this is considered to be "balance billing"
and is prohibited by Medicare law. These mandatory "write ofts" are referred to as
"contractual allowances."
J.
"Allowables"
For each payor category, we included an estimated "allowable" percentage. This
can be confusing, but an "allowable" percentage is the percentage of the payor-approved
charges that MCFRS can expect to
be
paid. In other words, once Medicare applies the
"contractual allowance" referenced above and determines·the "approved charge," Medicare
only pays the provider 80% of that approved charge. The remaining 20% is a copayment,
which is the responsibility of the patient.
As
state above, in this model, we assume a
Medicare copayment collection rate of 52% from "MedigapW insurers, which generally pay
these copayment amounts,.without regard to residency status, automatically after Medicare
makes the primary payment.
.
We utilized a
100%
"allowable" figure for Medicaid and commercial payors, but,
again, remember that this is
not
the same as assuming a 100% "collection rate" from these
payors. This merely means, to use Medicaid as an example, that Medicaid can be expected
to pay 100% of
its
approved charge
for ambulance services (currently, $1oo) and
not 100%
of MCFRS's actual charges.
We utilized a collection rate of 30% for self-pay accounts O.e., the estimated 10% of
the self-pay category that are non-residents}, again reflecting the likely adoption of an
"insurance only" billing policy for residents.
K.
Patient Care Documentation
One key variable not reflected in these prOjections is that EMS billing is only as good
as the field documentation that supports
it.
For instance, EMS providers must thoroughly
and accurately document information necessary to support proper billing decisions,
including patient condition, treatment and other clinical factors, and must collect signatures
of patients (when possible) or other authorized signers at the time of service. The County
should provide periodic documentation training for all EMS personnel in the County to
ensure that legally defensible and compliant documentation is completed in all cases.
Inadequate or inaccurate completion of patient care reports can negatively impact projected
revenues. The County's January, 2010 implementation of an electronic patient care
reporting (ePCR) system will undoubtedly be a significant benefit in producing quality EMS
documentation as well as reliable EMS data.
Montgomery County, Maryland
Updated
2010 EMS Transport Revenue Projections
(March
19,2010)
Page 9
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III. Revenue Projections
A.
Total Cash Receipts
We have broken down projected cash receipts by each payor, and then calculated
an overall total. Year One revenues are projected at approximately
$14.1
million. Years
Two - Four projections are approximately
$14.6
million,
$15.2
million and
$15.7
million,
respectively. Again, County policymakers and budget officials must take into account the
assumptions and limitations discussed above when budgeting anticipated revenues from the
EMS transport fee program.
B.
Average Revenue Per Transport
For each year, we project an Overall Projected Average Revenue Per Transport.
This is a simple calculation of gross cash receipts divided by total transport volume in a
given year.
This
takes into consideration all revenues from all payor sources and all levels
of transport, but it is a helpful "global perspective" of billing performance.
It could be argued that the Average Revenue Per Transport estimates, which are
approximately
$247,
are optimistic. Of course, this is directly related to the rate structure
that the County's poficymakers ultimately decide to put into place. Nevertheless, we have
compared Montgomery County to other jurisdictions and believe there are some compelling
reasons why these Average Revenue Per Transport estimates are reasonable.
First, Montgomery County has a comparatively high median household income.
According to U.S. Census bureau statistics, Montgomery County median household income
in
2004
was
$16,957,
compared with
$57,019
for all of Maryland. This puts Montgomery
County in the highest median household incomes in the United States. Given this statistic
alone, some could argue that our Average Revenue Per Transport estimates are
too
conservative.
Second, we compared these Average Revenue Per Transport Estimates with other
jurisdictions in the U.S. (using data available to us in
2008).
While these data do not always
take into account the same factors, and thus creates a potential problem of comparing
"apples and oranges," these data can be informative. For instance, in Dayton, Ohio
(according to data obtained from that City's ambulance billing contractor), a city with a
median household income of
$34,918
and approximately
16,000
EMS transports per year, .
the average revenue per transport was
$217.
On the other side of the spectrum, in Nassau
County, New York, with a medial1 household income
($80,641)
comparable to Montgomery
County's, and
42,106
annual transports, the average revenue per transport reported by their
billing contractor is
$380.
We therefore believe that the Average Revenue Per Transport
estimates in this revenue projection are realistic, again, depending upon the rate structure
implemented by Montgomery County.
C.
Gross and Net Collection Percentages
One common EMS billing measurement is the "collection percentage."
Understanding your projected collection percentage is vital when evaluating the ongoing
effectiveness of an outside billing contractor.
Montgomery County., Maryland
Updated
2010
EMS Transport Revenue Projections (March
19.2010)
Page
10
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When measuring collection percentages, it is critical to distinguish the concepts of
"gross" versus "net" collection percentages. Gross collections look at actual cash receipts
divided by total charges. Net collections, on the other hand, look at actual cash receipts
divided by the amount the provider is allowed to collect for the particular service, after the
mandatory contractual allowances required by law are deducted. While both of these
measurements of billing performance have their weaknesses, the use of a gross collections
percentage as a measurement of billing performance is highly artificial.
Consider the following example. Say that an agency
charges
$600 for a BlS
emergency call. Now, say that Medicare only
approves
$250 for a BlS emergency. Under
the law, as discussed above, your agency must write off the difference between
its
charge
and the Medicare approved amount. In this example, that ·contractual allowance" would be
$350. Under a gross collections approach, assuming you were fully paid by Medicare, and
succeeded in collecting the 20% patient co payment (which likely would not be the case with
Montgomery County residents), you would only have collected 41.7% - or$250/$600.
However, under a net collections approach, your agency collected everything
it
was allowed
to collect under the law, so your net collection percentage on this claimwas 100%.
The gross vs. net collections approach - as shown in this example - illustrates how
relatively easy it is to "manipulate" your "'collection percentage" merely by adjusting your
actual charges. For instance, say the ambulance service in our example above decides to
increase its BlS emergency charge from $600 to $800. Now, its gross collection
percentage on the sample claim drops to 31 %. or $250/$800. The amount approved by
Medicare doesn't increase merely because your charges increased, so the result is a drop in
your gross collection percentage. However, the amount of cash you actually received
stayed the same. So, on paper, your billing operation, when measured by a gross collection
percentage, looks like its performance is getting worse, when actually
it
may be unchanged,
or even better when you look at actual cash received. The reverse of this example is also a
potential pitfall: lowering your charges would have the result of artificially
Increasing
your net
collection percentage, while not necessarily improving your cash receipts, thus perhaps
making billing performance seem better than it is.
We projected both gross and net billing percentages for purposes of this report. The
estimated gross collection rates are, conservatively, lower than reported national averages.
For instance, the Jems 200 City Survey in 2007 reported that the average gross collection
percentage for public-sector EMS agencies was
55.9%.
Our gross collection percentage
estimates for Montgomery County run
in
the 50-51
%
range.
It is likely that lower gross collection percentage estimates do result in higher
net
collection percentage estimates. This is because a lower gross percentage means that
more of the "unallowed» charges have already been written off, leaving more "pure" and
collectible revenue on the table. Therefore, one would expect that the net collection
percentages would be higher. There are no meaningful, national net collection data
reported of which we are aware. Nevertheless. again, because the net collection percentage
represents income to which the County is legally and legitimately entitled, and already
factors in the allowed amounts, contractual write offs and very low estimated self-pay
percentage, we believe that the net collection percentages represent realistic expectations
for a billing contractor to achieve for a county as affluent as Montgomery County, Maryland.
Montgomery County, Maryland
Updated 2010 EMS Transport
Revenue
Projections
(March
19, 2010)
Page 11
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IV. Conclusion
Though based on many variables that are subject to change, these EMS billing
revenue projections demonstrate that there are substantial revenues that could be realized
were Montgomery County to implement an EMS transport fee. Of course, the decision on
whether or not to do so, and on how any realized revenues would be allocated, is up to the
sound discretion of the County's policymakers.
V. Important Notices
These projections are estimates only and not a guarantee of financial performance.
All projections are based in large part upon data supplied by the client. Estimating revenues
from the provision of any health care services involves many variables that cannot be
accounted for in a revenue estimate and that are beyond the control of the estimator. The
conSUltants have stated all key assumptions and have provided a relational spreadsheet
that allows the client to modify any assumptions that it finds necessary. The client is
responsible to verify all assumptions that affect these projections and to modify them when
necessary. This estimate does not constitute the rendering of professional accounting
advice, and does not take any expenses into account. Revenue projections can also be
impacted by changes in applicable reimbursement laws and regulations. The consultants
are not responsible to update this analysis unless asked to do so by the client. Finally, the
decision to undertake EMS billing rests entirely with the client, and the client bears all
responsibility for appropriate and compliant billing operations•.
Montgomery County, Maryland
Updated 2010 EMS Transport Revenue Projections (March 19,2010)
Page 12
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Appendix A
Year One Revenue Projections
Updated
03/1911
a
Montgomery County, Maryland
Updated 2010 EMS Transport Revenue Projections (March 19.2010)
Page 13
@
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Total
Projected
Transport
Volume'
Est.
Medicare
Transports
(40%1
2
Est.
Medicaid
Transports
(40/.)
Est.
Commercial!
Auto
Transports
(28%)
47
i
719
1
.---
­
.
3,172,008
218,712
1 ---
- - t - - ---1
Miles (A0425) (AveragefTrip)
Est. Medicaid
Est.
%
of
Total Medicaid
Approved
Charges
Total Medicaid
Cash Receipts
2,300
11--_
_
123,000
2.300
1
1---__
-+-__
95,700
J--_
_ _
+-­
4,800
©
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PalOr: Self-Pay (28%J
_
BLS-NE (A0428)
BLS-E (A0429)
ALS1-NE (A0426)
ALS l-E (A0427)
ALS2 (A0433)
SCT (A0434)
Loaded Miles (A0425)
(Average/Trip)
Est.
%
of
Transports
1%
$
54%
$
1%
$
Charges
300
400
350
500
700
800
8
Est. Self-Pay
Transport
Volume
160
8,615
160
6,700
319
N/A
Total Non-
Est. Non-
Total Self-Pay Resident Self-
Resident
5
Charges
Pay Charges Collection%
Total Self-Pay
Cash Receipts
$
47,861
3,445,969
55,837
3,350,248
223,350
4.786
344,597
5,584
335,025
22,335
63
,816
30%
$
1,436
103,379
1,676
100,507
6,700
-
$
$
$
$
$
$
-
30%
$
30%
$
30%
$
30%
$
30%
$
30%
$
-
42%
$
2%
$
0%
$
5
-
-
'
-
79,770
-
638,160
$
-
-
19,145
232,~
--
GRAND TOTALS­
­
$
27.71
9,535
$
24.998.421
TOTAL
L
-
-
-
CHARGE~APPROVEOCHARGES
-
.-
GRAND TOTAL - PROJECTED CASH RECEIPTS - YEAR ONE
OVERALL PROJECTED AVERAGE REVENUE PER TRANSPORT
GROSS COLLECTION PERCENTAGE
NET COLLECTION PERCENTAGE
$14,143,139
248
$
51%
57%
-
_
..
.
Footnotes:
1 Transport volume is based on estimates provided
~y
Montgomery County Fire Rescue
-+
I
I
1
I
--­
2 Estimated number of Medicare transports per level of service estimated based on comparable MONA jurisdictions
3 2010 Medicare rates taken from 2010 Ambulance Public Use File from the Centers for Medicare and Medicaid Services
4 Medigap estimate is 52% of total Medicare copayments; Medicare copayments are 20% of Medicare approved charges
5 Non-resident self-pay charges estimated to comprise 10% of total self-pay charges
-
-- ­
-
-
~~.
-
Billing for an!:: health care service involves man!:: variables that cannot be accounted for in
a
revenue estimate and that are be'i"ond our control.
This
;s
an estimate onl,;, and does not constitute
a
guarantee.
I
I
I
I
,
-_.
-
-
I
®
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Appendix B
Year Two Revenue Projections
Updated
03/19/10
Montgomery
Maryland
Updated 2010 EMS Transport Revenue Projections (March
2010)
16
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Est.
Total
Projected
Transport
Volume
1
Est.
Est.
Medicare
Medicaid
Commercial!
Auto
Cash Receipts
7:
II-
- -
-
--+-­
2.•
,700
.
Est.
%
of
Transports
----+---~
~
--+I----~--~--
~ ~ -
®
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Est. Non-
Resident
Total Self-Pav
Payor: SeIf.payj28%)
BLS-NE
(A0428)
-
Tran~orts
1%
$
54%
$
1% $
42% $
2% $
5
Charges
300
400
350
500
700
8
I
Volume
-
166
8,960
166
_
_
,
-
1-
I
.
_,___
,
,
_--J-'----+----J
., ___
,
I
__
._
__
--
,
~
LS-E
(A0429)
-
,--
'
,_
n
---, ,--
,
-
'-
-
j
'_
1
~
1
__
" _
I - -
.
--
---
;1--
..
1
-....
~1-NE(A0426)
IALS1-E(A0427)
ALS2 (A0433)
~ded
Miles
(A0425)
(Average'!'rip)
--'--
1
---1
- - - + - - --1
-(
6
,
96~
.
..J
3321
_
,-
_,._.
,_n
,
_'_
"
n
i
n
'-
i
-
.
- - - - --
t - - --
t
I
$
I
79,770
I
,
_
'
$
-I
.
n
,
-
fo%1
$
I
-L
.-.-
.-
i.
----I- ___
~
J
f-
GRAND TOTALS­
CHARGES/APPROVED CHARGES
lOTT
"'~
~_-I--
_ _ _
-+1_
_
29.312
,518
1
$
25.917
.259
$
GRAND TOTAL - PROJECTED CASH RECEIPTS - YEAR TWO
OVERALL PROJECTED AVERAGE REVENUE PER TRANSPORT
GROSS COLLECTION PERCENTAGE
NET COLLECTION PERCENTAGE
Footnotes
:
L
1
-
--
~~-~~~----
$14,663,456
_ _ _
+-_ _
- j
$
247
50%
-
- --1­
57%
j
-1
--
r
1 Transport volume is based on estimates provided by Montgomery County Fire Rescue
2 Estimated number of Medicare transports per level of service estimated based on comparable MONA jurisdictions
~
+--
----+-----1---
- --+----+--
­
2010 Medicare rates taken from 2010 Ambulance Public Use File from the Centers for Medicare and Medicaid
Service
~
4 Medigap estimate is 52% of total Medicare copayments; Medicare copayments are 20% of Med
icare
approved
_
cha--" es_
_
_
_
-l-_ _ _ _f­
_ _
rg,._
5
Non-resident self-pay charg es estimated to comprise 10% of total self-pay charges
I
L
I
Billing for anv health care service involves many variables that cannot
be
accounted for in
a
revenue estimate and that are beyond our control.
This is an estimate onlv and does not constitute
a
Quarantee.
I
I
I
----.
I
,
®
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Append
Year Three Revenue Projections
Updated
03/19/10
Montgomery
Updated 2010
2010)
19
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Total
Projected
Transport
Volume
1
Est.
Medicare
Transports
'40°.4)z
Est.
Medicaid
Transports
(4%)
Est.
Commerclall
Auto
Transports
(28%)
Est. Self-Pay
Transports
(28%)
Est. Medicaid
Total Insurance
Approved
Charges
--r---------~---
@)
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I
Paror: SeIf.payJ28%)
__
BLS·NE
(A0428)
BLS·E
(A0429)
ALS1·NE (A0426)
ALS1·E (A0427)
SCT
(A0434)
~d
Est.
%
of
Transports
1%
$
54%
$
1%
$
42%
$
2%
$
0%
$
5
Charges
300
350
500
700
800
8
Est. Self.Pay
Transport
Volume
173
9.318
173
7,247
345
N/A
-
-
Total Non·
Est. Non·
Total Self·Pay Resident Self·
Resident
5
Charges
Pay Charges Collection%
Total Self·Pay
Cash Receipts
.
- -
400
$
$
$
$
51.900
3,727
.200
60,550
3,623,500
241
,500
.
5.190
372
,720
6,055
362,350
24,150
63
,816
30%
$
30%
$
30%
$
30%
$
30%
-
30%
~(A0433)
$
$
$
Miles
(A0425) (AveragefTrip)
--
­
.
79,770
S
S
1,557
111,818
1,817
108,705
7,245
_
19,145
210",
$
638,160
30%
$
-
f-
.
-
TOTAl S
-
.-
~
r----­
GRAND TOTALS ­
CHARGES/APPROVED CHARGES
$
29
.795.420
$
26
.872 .970
GRAND TOTAL - PROJECTED CASH RECEIPTS - YEAR THREE
OVERALL PROJECTED AVERAGE REVENUE PER TRANSPORT
GROSS COLLECTION PERCENTAGE
NET COLLECTION PERCENTAGE
$ 15,204,284
247
$
51%
57%
--
-
Footnotes:
I-
-
I
1 Transport volume
is
based on eslimates provided by
Montgomery
County Fire Rescue
I
-
I
I
-
_.
2 Estimated number of Medicare transports per level of
service
estimated based on comparable MONA jurisdictions
~
3 2010
Medicare
rates taken from 2010
Ambulance
Public Use File from the Centers for Med
icare
and Medicaid Services
Medigap estimate is 52
%
of
lolal Medicare copayments
;
Medicare
copayments
are 20% of Medicare approved charges
5 Non-resident self·pay charges estimated to comprise 10% of total self-pay charges
-
-
-
Billing for anlC: health care service involves
manIC:
variables that cannc:>t be accounted for in
a
revenue estimate and that are belC:ond our control.
This is an estimate onllC: and does not constitute
a
guarantee.
I
I
I
I
I
I
®
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Appendix D
Year Four Revenue Projections
9/10
Montgomery County, Maryland
Updated 2010 EMS Transport Revenue
(March 19, 2010)
22
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Total
Projected
Transport
Volume
1
Est.
Medicare
Transports
(400/.)2
Est.
Medicaid
Transports
(4%)
Est.
Commerciall
Auto
Transports
(28%)
Est. Self.Pay
Transports
(28%)
Est.
%
of
Est. Medicaid
Transport
Volume
Total Insurance
Cash Receipts
::It--
­
.;81.
~
®
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Payor.
BLS-E (A0429)
SeIf-P,yJ28%l
-
Est. % of
Transports
1%
$
54%
$
1%
$
42%
$
2%
$
0%
$
5
Charges
300
400
350
500
700
800
8
Est. Setf.Pay
Transport
votume
179
9,690
179
7,537
359
79,770
N/A
Total Non·
Est. Non·
Total Self-Pay Resident Self-
Resident
5
Pay Charges Collection'!.
Charges
BLS-NE
(A0428)
ALS1-NE (A0426)
ALS1-E (A0427)
ALS2
(A0433)
SCT (A0434)
Loaded Miles (A0425) (AveragefTrip)
$
$
$
$
$
$
$
53,700
3,876,000
62,650
3,768.5
~
5,370
387,600
6,
265
376,850
25,130
63,816
--
Total Self-Pay
Cash Receipts
30%
$
-
251
,300
.
-
- -
-
$
638,160
-
GRAND TOTALS­
CHARGE&APPROVEDCHARGES
f-
I-­
$
30%
$
- ­
30%
$
30%
$
-
30%
$
30%
,
$
TOTAL
$
30%
1,611
118.280
1.880
113,_
7,539
19,145
219,109
-
- ­
-
._-­
$
30,894,220
$
27,865,464
GRAND TOTAL - PROJECTED CASH RECEIPTS - YEAR FOUR
OVERALL PROJECTED AVERAGE REVENUE PER TRANSPORT
GROSS COLLECTION PERCENTAGE
NET COLLECTION PERCENTAGE
Footnotes:
$
15,766,039
246
$
--­
51%
57%
I
I
I
I
I
1
I
-
-
-
1 Transport volume is based
on
estimates provided by Montgomery County Fire Rescue
2 Estimated number of Medicare transports per level of service estimated based on comparable MONA jurisdictions
-
----_.
--­
-
I
I
I
2
2010 Medicare rates taken from 2010 Ambulance Public Use File from the Centers
for Medicare
and
Medicaid
Services
4 Medigap estimate is
52%
of total
Medica
re copayments; Medicare copayments are 20% of Medicare approved
charges
5
Non-resident
self-pay charges estimated to comprise 10% of total self-pay charges
I
Billing for anI!: health care service involves
manl!:
variables that cannot be accounted for in
a
revenue estimate and that are bel!:ond our control.
I
This is an estimate onll!: and does not constitute
a
guarantee.
I
I
I
I
I
I
®
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Appendix E
EMS Rate Setting Article
Montgomery County, Maryland
Updated 2010 EMS Transport Revenue Projections (March 19,2010)
Page 25
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How
SHOULD YOUR AMBULANCE
SET
ITS
SERVICE
RATES?
LEGAL
CONSULT
Uyour EMS organization charges for its serv­ above that approved amount (except for his
('<\~
lees, you probably spend days, weeks or or her deductibIe-lf
applicabl~r
co-pay­
.
months learning
aU
the complex rules
about
ment). So you
must
write off the dlfferente
billing. But
If
you ask administrators how between your rates and the Medicare fee­
they
set their rates, many will provide
an
schedule rates.
answet that
is
only slightly more advanced
Knowing these c.ontractual allowance
than
"We
pull
them
out of thin alr. However. amounts will prove critical
In
measuring.
whether your service is public. private or your billlng performance. Many
EMS
organi­
not-for-profit. proper rates are crucial to your zations focus on ca1ctllating collection per­
organization's overall success, and a rate-set­ centages, but be sure you measure perform­
ting strategy that complies with the law is ance consistently. Gross collection
p~cent­
ages measure the amount collected versus
INCISIVE ANALY.SIS OF
fundamentaL
First
and foremost, start by taking accurate the total amounts billed. Net collection.
EMS LEGAL TOPICS
measure of your organization's costs. This percentages-which generally provide
a
includes an assessment not only of such big­ more meaningful measurement
of
billing
ticket line items as personnel. vehicles. performance-evaluate the total amountcol­
equipment and Insurance, but also an assess­ lected versus the
total
amounts billed,
ment of fuel, maintenance, heat, electricity · minus the contractual allowances that the
and
all other overhead elements. Don't forget law requires you to
write
off.
depreciation; part of your revenues must go
Another fundamental decision your
orga:n~
toward replacing capital assets In thl'! future ization must make
with
regard to rates is
as
well
as
to support current operations. whether
It
will
bfU
for serviCes on a bundled
These costs must be arnortized-or spread or an unbundleq basIs.
A
service using bun­
over
your expected call volume-and must dled
billing
rolls
all
charges for suppUes,
allow for the possibility of bad debt or uncol­ · services, etc., Into one base rate charge
(typ­
Iect1ble accounts. so your rates
reflect
the ically bill1ng only mileage separately).
A
true costs of dofng business.
service that uses unbundled
billing
may ( )
Next,
consider whether- your organlzation charge separately for such thIngs
as
oxygen,
operates in
a
rate-regulated environment. disposable supplies, walt time and
extra
While only a small handful of states (e.g., attendants.
Though Medicare no longer pays on an
Arizona,
Utah
and ConnectIcut) regulate
rates at the state level, some local govern­ . unbundled basis and considers all these
ments may establish ordinances or laws that ancillary charges to be part of the provider's
set ambulance rates or establish maximum base rate, other payers may
still
recognize
fee schedules. Even
if
your locality has no these separate charges:-.So your service
such local law or ordinance, some contracts should consider the ramifications of charging
between ambulance services and the areas those payers on a bundled versus unbundled
they serve Include rate stipulations, so be basis before deciding how to bill them.
Important:
Remember when
setting
your
sure to consult your municipal contracts for
rates
that
Medicare will pay only the lesser
any
applicable rate restrictions.
(
An
ambulance service that 15 not rate­ of either the approved fee schedule amount
regulated generaUy
has
a sIgnificant degree or the amount. you bill. In other words,
if
you
of flexibility In setting its rates.
In
fact, charge less than the ,Medicare-approved
your organization can price its services as
It
amount, MedIcare will pay only up to the
sees fit and can generally raise those rates at amount of your bill. For that reason, and
because Medicare -is the single largest payer
anytime.
Of course, not every payer will reimburse for most ambulance servIces, you should
you for
100%
of your bill, so you must ensure that your rates, are higher than the
also factor these mandatory write-offs Medicare-approved amounts for your vari­
(called contractual allowances) into your ous levels of
se~ce;
otherwise,' your agency
rate-settlng. Medicare, for Instance,
will
only leaves legiti,mate revenue on
th~
table.
Many EMS admlnlstra,!prs mistakenly
pay amounts approved under the
Ambulance Fee Schedule, and the patient believe that an ambulance service must
cannot be "balance billed" for anything · charge all payers the exact same rates. This
K
Thi.
column is net intended
allegal
a.tvla Qr leg.1 counsel in
the
c01lfines
ofan attllmey­
di.t1t
relacionship_ Consult an attorney
ro,
specific legal
aova
concerning )'Our
situation.
z
FEBRUARY 2007
Ii
EMS INSIDER
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..
'-
'"
O
generally is Dot the case, however:
Ambulance services
oIten
charge different
rates in different circumstances.
For
instance,
if
your
organization partici­
~ates
In
a managed care network
as a.
COD­
{
tracted
provider, you might have
a
rate
schedule in your agreement with a
particular
HMO
or
health
plan
that is lower than yout
r.etail rate schedule. In some cases, rates
charged to
a
facUlty; such as
a
hospital
or
: nursing home, also may dJffer
from
;your
agency's retall rates.
Another Important reminder:·. Although.
provid~s
generally may
charge
different
rates '
under various
cir­
cumstances,
remember that
your
rates must
cotnply
with
such
laws as the feder­
al antl-kickback
, statute.
For
example,
if
~uch
you discount
the
rates you
charge
a
facility,
It
could
appear that those discounts
were
given In
exchange
for
the
facility's
referral of
Medicare patients to
your service,
which
COuld
constitute an Ulegal
inducement
and
, give rise to a violation of the AKS. (Much has
been written about the AKS and Its applica­
tion to ambulance servlces
in
the pages of
o
the
EMS Insider
in recent
years.)
A final caveat: Setting your rates should
not
be
a
group exercise.
In
other
words,
to
avoid raIsing Issues under state or federal
antitrust laws,
your
organization must not
establish its rates based on
diSCUSSions
or
agreements
with
your competitors .or
with ..
other services in your
area.
This
kind
of <;on­
duct could
be seen
as price
fbdng and
can
have serious
legal
consequences.
Aithough.
you,
will
need
to
c<;>nsldex:
other issues when setting rates, these are
the· primary cQnsideratiQns. Within
.the
broad
parameters of
state and
federal.laws,
Although
providers
generally
may
charge
different rates
under various circumstances,
remember
th~t
your rates
must
cori-.pJy
with
laws
as the
federal anti-kickback
-statute..
most
ambulance
services have great
flexibiJ..
tty
in establishing rates and charges for their
services.
Your organization
w:Ill
be
best served
n.
you give your
rates
the thought and
!ltten­
tion. they deserve instead of
merely
pull1ng
them
out
of thin
air.
Help OSHA Revise Its
Emergency~Response
Regulations
The Occupationa.l Safety and Health Administration currently covers emer­
gency
respondersafety as part ofseveral standards, some ofwhich are decades
old and out of date. Consequently, OSHA
is
working to develop a single, uni­
fied
set of
revised regulations, and is soliciting input &om the emergency­
response community
by
May
1
on what the revised
regulations
should indude.
For
more
information 3J1djor
to
contribute to this
effort.
visit www.dol.govjoshajregsjunified
agenda./2127.htm.
Wait
to
Respond to AMR,
IAFe
Advises Fire Departments
The International Association
of Fire Chiefs
on
Jan. 4 asked
fire
departments
to
hold
off.
on responding
to
an
American Medical Response sdlicitation to EMS providers nationwide
to
agree to provide
ambu­
lance services during large-scale
disaSters "until
the IAFC
and
the Federal EmergencyManagement Agency
can identifY
if
the fire service can
fill
the potential need." Acc.ording to IAFC, FEMA
"h;tS
placed a hold on
this initiative until
it
can review
the
work
and
recommendations of
the (rAFC] Mutual
Aid System
Task
force.» IAFC
predicted
that
the
association
and
FEMA
would
be
able
to
"resolve
this
issue
and provide
additional guidance by February
2007."
For more infurmation,
visit
www.iaft.
org or can'tact
Lucian
Deaton,
lAFC EMS
~agerjgovem
menbd
relations at Ideatoo@iafi:.org.
EMS INSIDER
!Ill
FEBRUARY
2007
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~_bl
..
Properly '''''
Rat",
leol Properly
flase: Reel
Properly
[!l00)
O.I03i
174.877,000
~.l"
Property Tax CoUedi"n Fador: R I Properly
....
Properly
Tax
Rat.:
P"rsanol Properly
Au••sable
Ba.e:
i'1l,.cmal Properly
(0001
Property
I""
Colledion Faclor: P........,,,I Property
Indirect Cost Rate
CPt (Fis.::al
Yoarj
0.256
4,210,792
97.~
0.00%
RWENU£S
T""""
Li<:on....
& P...,."its
Charg...
for
S""'i....
Fin...
&
Forfeituros
Inlargovemman",1
Subtotallle¥enues
Mia""""'"",,""
GO Bonda
INTERI'UND
lIZ, I
Bl
,650)
(7,890,200)
Fi....
and
Rescue
Fuel
McnagemMl Sym,m
Pi",
cnd
Re.c:ue !!qui""",ltt
IAPpcr.>lu.
Mgmt.,
Transfers To
GenerQl
Fund
FY1 0 Fund
flalal'l<e
n,.;
(568,250)
(3.n3,200)
(120,750)
o
(120,750)
OCM
2!lO,ooO
ClP
c:UIUtENT
IIVENUE APPROI'.
0
(187,967
312,680
(335,380J
148,060
(3,001,000]
(309,~101
PSI' OPIR. BUDGET APPRO..! EXP'S.
O"",,:lIlng
Budget
Labor
Agreement
[187,~67,9701
0
312,6BO
(335,380)
Annualizations and One-lime
Apparotu.
Replacement
Capital Operating Budget
Im~ocls
Eleclronic Pationt
Care
It''porting
n/a
ala
216,530
[309,510)
(13,968,0001
"/a
n/a
n/a
n/a
n/o
n/a
0/0
Pour Person Staffing
M1..tana and King..,;_ Amh"loncas
Malo,
Pool
Rat.
Adju>ImMl
R""ruit Cia.. Staffing
Cost
SAFER Onsnt cia!!
Subfot<ll PSI" Oper Budget ApproI'
/I!xj>'s
n/a
n!a
n/a
n/a
(10,.476,000)
11,350,0001
(401,5201
(1.350,000)
{401.~201
12,280,000)
I
1839.210)'
(2,180,0001
(839,2101
YEAR
END FUND
BALANCE
END-Of·nAII1lE5111V1S AS A
6,,418,730
5,824,500
5,046,300
PERCENT OF Il£SOUllCES
Assumptions:
1. The tax rates for the Consolidated Fire TCIX District are adjusted to mairrlain a fund balance
of
approximately 2.5 percent
of
resources.
2. The I.c:bor contract with tM International Association of Fire Fighters, Local 1664 expires at the end of FY11.
3.
The
labor contract with the Municipal and County Government Employees Organixalion, Local 1994 expires at the end
of
FY11.
4. These projections are based on the Executive's Recommendod Budget and indude negotiated labor agreements,
the
operating costs of
capifCll fi:lcilities, the fiscal impact of approved legislation or regulations, and other programmatic commitments. They-do
nat
inc:!ude inflation
,or unapproved service improvements. The projected future expenditures, revenues, and fund balance may vary bl:lset\ on changes
to
fee
or
lux
irates, usage, inflation, future labor agreements, and otherfaclol'S nol assumed here.
5.
The
costs
of capital facilities will
be
included in future budgets as projects are campleied and their costs defined. Implementation
of
additional phases of the Four-Person Staffing initil:llive and other staffing improvements Qre presented here for iUustratiVQ purposes. Staffing
decisions will be reviewed and determined on an annual basis.
12
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FY 2009/2010 Federal Poverty Guidelines - LIHEAP Clearinghouse
Page 1 of 1
2009/2010 HHS Poverty Guidelines
SEARCH
For all states (except Alaska and Hawaii) and for the District of Columbia
185
175
Percent
Percent
of
of
Poverty
Poverty
$18,953 $20,036
$25,498 $26,955
$32,043
$33,874
200
Percent
of
Poverty
$21,660
$29,140
$36,620
$44,100
$51,580
$59,060
$66,540
$74,020
• State Programs
o Plans/Manuals
o Administration
o LIHEAP
components
o Client eligibility
o Benefits
o Self-sufficiency
o Leveraging
• Tribal LIHEAP
o Manual
o Funding
o Agreements
o Applications
o Benefits
o Leveraging
o REACH
• LIHEAP Funding
• Public Benefits
o State summaries
o Studies/reports
• Disconnect Policies
• State Supplements
o Recent year
o Previous years
• LIHEAP Directors
o States/websites
o Tribal
o Insular areas
• Publications
o REACH
o Leveraging
o Benefits/eligibility
o Other LIHEAP
• Related Links
o Community action
• State/regional
• Local
o Low income/energy
o Federal government
Size of
family
unit
1
2
.)
100
Percent
of
Poverty
$10,830
$14,570
$18,310
$22,050
$25,790
$29,530
$33,270
$37,010
110
Percent
of
Poverty
$11,913
$16,027
$20,141
$24,255
$28,369
$32,483
$36,597
$40,711
125
Percent
of
Poverty
$13,538
$18,213
$22,888
$27,563
$32,238
$36,913
$41,588
$46,263
150
Percent
of
Poverty
$16,245
$21,855
$27,465
$33,075
$38,685
$44,295
$49,905
$55,515
""
4
5
6
7
8
$38,588 $40,793
$45,133 $47,712
$51,678 $54,631
$58,223 $61,550
$64,768 $68,469
For family units with more than 8 members, add $3,740 for each additional person at
100% of poverty; $4,114 at 110 %; $4,675 at 125%; $5,610 at 150%; $6,545 at 175%;
$6,919 at 185% and $7,480 at 200% of poverty.
Note: For optional use in FFY 2009 and mandatory use in FFY 2010
Page Last Updated: April 5,2010
http://liheap.ncat.org/profiles/povertytables/FY20 1O/popstate.htm
4/2212010
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2009 UPDATE OF THE
FIRE, RESCUE, EMERGENCY MEDICAL SERVICES, AND
COM:MUNITY RISK REDUCTION MASTER PLAN
responsibility for ALSIBLS quality assurance for a designated area although permitted to
respond elsewhere in the County as needed. While progress in achieving the existing
recommendation has occurred, five additional EMS Officer positions are needed,
including two that had been funded with overtime monies and one for the recommended
6
th
Battalion (reference: Master Plan Recommendation #33).
Recommendation 41
Revise Recommendation #41 to indicate MCFRS' new ALS service delivery model
involving the use of
alternatively~staffed
medic units and increased use of ALS first­
responder apparatus (AFRA). The department's intent is to implement the "1 and
I"
ALS deployment model incrementally, whereby minimum staffing composition of medic
units
is
changed from two paramedics to one paramedic and one Emergency Medical
Technician (EMT) - typically a firefighter. The second paramedic position on existing
medic units would
be
reassigned to serve as the fourth position (Le., firefighter­
paramedic) on an engine (or in one case on an aerial unit) at the same station as the medic
unit, thus creating an AFRA in addition to the medic unit. The AFRA would typically
respond along with that station's medic unit, or another available medic unit, to ALS
incidents.
This
ALS delivery model would provide for the collective response oftwo
paramedics and four EMTs (between the AFRA and medic unit), thus increasing the
effectiveness ofALS patient care while also meeting NFPA Standard 1710 staffing
requirements for engines with regard
to
fire suppression.
The
"I
and
I"
ALS deployment model, which has been implemented successfully at
several MCFRS stations
to
date, accomplishes the following objectives:
• Increases ALS service delivery to the public: The
I
a:rld 1 ALS deployment
model greatly increases the number of MCFRS units capable ofproviding ALS
services
to
the public; although only medic units have ALS transport capability.
By placing a paramedic (fIrefIghter or officer) on designated engines as the fourth
person, these engines can provide ALS service, with transport being provided by
an EMS Unit. With a greater number of ALS units (i.e., AFRAs and medic units)
in service, ALS response time has improved county-wide.
• Provides for a more effective utilization of available paramedics: MCFRS data
indicates that on only about 7% of ALS incidents are two paramedics needed for
providing patient care during transport. On over 90% of ALS incidents, therefore,
the AFRA is able to return immediately to service with four personnel on board,
including the firefighter-paramedic or officer-paramedic (Le., fourth person on
AFRA), ready for the next ALS, fire, or other type ofincident. On less than 10%
of ALS incidents does the AFRA paramedic join the EMS transport unit's
11
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2009 UPDATE OF THE
FIRE, RESCUE, EMERGENCY MEDICAL SERVICES, AND
COMMUNITY RISK REDUCTION MASTER PLAN
paramedic or EMT2
in
transporting patients to the hospital, while the engine
returns to service as a three-person unit, minus the paramedic until that individual
returns to the station from the hospital.
• Provides paramedics with an enhanced opportunity to integrate into fire
suppression activity: This broadens career development opportunities for current
paramedics and serves as incentive for more firefighters to become firefighter­
paramedics, with the knowledge that they can remain in suppression services
while serving as paramedics.
The new model is tied directly to the revised phases of fourth-person staffing of
suppression units as described in Recommendation #32 above.
Recommendation 68
Replace the matrix of fire-rescue response time goals on page
5-54
with the attached
revised matrix (Figure 5.6). Changes are shown in boldface font. The primary change
involves EMS response time goals to reflect the five categories of EMS calls - "Alpha,
Bravo, Charlie, Delta, Echo" - used in the Emergency Medical Dispatch (EMD) protocol.
Other changes include the addition of response time goals for
5
th
due engine on box
alamlS, 3
rd
due aerial unit on high-rise box alamlS, and command officers on major fire­
rescue incidents. Another revision involves the perfonnance levels (i.e., percentages)
associated with the three density zones, where all urban goals have been changed to the
90% perfonnance level, all suburban goals to the 75% level, and all rural goals to the
50% level for consistency purposes.
3
In
addition, a column showing corresponding
NFPA 1710 response time guidelines
has
been added for comparison purposes.
One change requiring explanation is the response time associated with the basic life
support (BLS) response goal from 6 to
12
minutes. The increase is due to a
philosophical premise: BLS incidents involve non-life threatening occurrences (e.g.,
sprains, fractures, contusions, unspecified sicknesses, etc.), so a longer response time is
acceptable. Because of this, units responding to BLS incidents may, in some cases, not
require use ofemergency
lights
and sirens (Le., travel in routine mode)4 which would
have the added benefit of a reduction
in
the number of collisions involving MCFRS
apparatus. The increase in BLS response time will also allow for greater emphasis on
advanced life support-"ALS" response (e.g., life threatening emergencies such as heart
ALS incident is oithe "Charlie"·level, then a BLS transport unit (staffed by EMTs) would transport
the patient lithe ALS incident is of the "Delta" or "Echo"-level, then a medic unit (staffed by one
paramedic and an EMT driver) would transport the patient
3
2
lithe
The lone exception is the goal for BLS response where the urban goal is 980/0, suburban goal
is 95%,
and
rural goal is
90010
due to the increased time associated
with
BLS response.
4,
A decision on allowing response oiBLS units in the routine mode for certain Alpha and Bravo-level
incidents will be determined at a later date by the Fire Chief.
12
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Review and Analysis of Fairfax County EMS Responses
2002
to
2007
Ambulance fee supporters claim that imposing a charge of
$300-$800/transport
will not
deter people from calling 911, often citing to the experiences of other jurisdictions. For
example, the EMS Transport Fee section of the County's website currently says:
"There is no evidence that those in need of transport will be dissuaded
from calling 911 because their insurance is going to be billed or
because they are uninsured. In the jurisdictions that have been
collecting this fee, there is no evidence of that happening."
(1)
Fairfax County began billing for ambulance service in 2005. While total EMS calls in
Fairfax County have increased steadily in the past several years, the number of calls when
corrected for population increases actually decreased from 2004 to 2005. Since that time,
EMS calls (when corrected for population growth) have remained below the 2004 level.
While the reasons for call volume changes are not clear, the statistics raise the question:
Why did EMS call volume drop from 2004 to 2005? And why has EMS call volume
remained below the 2004 level?
Before any ambulance fee is imposed, credible studies or analyses should be performed
(e.g., through surveys of impacted populations) to determine whether, in fact, ambulance
fees have deterred some Fairfax County residents from calling 911.
,
• Fiscal Year
2002
2003
2004
2005
2006
2007
Sources:
(1) http://www.montgomerycountymd .gov/mcgtm pl.asp?urf=/contentlpio/ems/facts. asp
(2)
http://www.fairfaxcounty.gov/frlstats/
Population
964712
984366
1007800
1041200
1049333
1077000
Call Volume
89,246
87,621
91,373
88,591
90,086
92,087
EMS
Calls
60,685
60,306
62,420
61,636
62,036
64,088
EMS Calls %
of Pop
6.29%
6.13%
6.19%
5.92%
5.91%
5.95%
Change
in
EMS Calls %
of Pop
- 0.16
+0.06
- 0.27
- 0.01
+ 0.04
5
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PI!
transport billing in Fairfax County.
,-/.!:3
-It)
My name is Christine Louder, EMS Deputy Chief, Fairfax County Fire and Rescue Department.
I am here tonight to provide information regarding the successful implementation of EMS
In 2004, the FRO convened a Stakeholders Panel to opening discuss the concerns regarding
billing for transport services. The panel was comprised of county staff from various disciplines,
representatives from volunteer fire departments, advocates representing senior citizen groups,
employee labor representatives, and representatives from minority groups in the county. This
Stakeholder Panel convened for 4 months in which they reviewed data, such as:
• All Virginia jurisdictions who bill and their rates
• Best practices- implementing a billing system
• Data regarding insurance coverage rates in the Nation, Virginia, and in Fairfax County
• Pertinent demographic data
• Attended seminars for Medicare/Medicaid
The Panel's guiding principle throughout the entire feasibility study was ensuring that the
system of providing Emergency Medical Services in Fairfax county remains caring and
compassionate, that the ability to pay is never considered when rendering service, and the
system continues to provide the highest quality care possible. Implementation of a fee for EMS
transport services should never change the way care is provided by the EMS providers in the
cout:\ty.
The panel voted unanimously to recommended that Fairfax County begin billing. The following
were their recommendations:
• Compensate the volunteers for documented lost revenue, the county decided to
compensate the 12 volunteer stations regardless.
• County enact appropriate controls and procedures to minimize the impact on county
residents.
o Office of Inspector General- co-pays associated with the bill (tax dollars paid)
o Billing for EMS transports should not impose additional tax burden on residents
o Insurance company costs should not increase EMS transport fee recover
constitutes less than 1 percent of Medical costs covered by insurance
companies.
• Rate structure that would maximize reasonable cost recovery
• Contract with a Billing Service, reduce county overhead.
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• Institute compassionate billing practice.
o Hardship waivers
o Bill waived by Deputy Chief EMS or FC, ex heroic events, disasters,
QA
o Will not use collection companies
• Staffing and additional funding
o Billing manager
o Health Insurance Portability and Accountability Act (HIPAA Officer)
o Patient Advocate (fulltime) not part ofthe panel joined during implementation
• Public media (9 months)
o All County citizens received a pamphlet in the mail
o Video played on the county TV stations and was available at the BaS's offices
o Many members of the department meet with many homeowners association
• Providers are not involved in insurance information exchange; this is coordinated
through the billing company and the hospital
As a result of EMS Transport billing for 5 years has collected
$
59 million.
Volunteer letter at the completion of 1 year of billing. Mark Sevello Vice Chairman Vol. fire
Commission
• Additional, operational training required for HIPAA, however training was integrated
into existing programs and did not create a burden.
• Fundraising, survey results have been mixed some reported lower return of
contributions some received higher levels of contributions.
• "The implementation project team accomplished a tremendous amount of work to
meet the implementation timeline establish by the BaS. The result is a billing process
that is functioning well and has had minimal impact on the service delivery for either the
provider or the patient."
Dispatched EMS incidents: patient care records did decrease between 2004·2005 due to a
flawed reporting system.
2000- 55,552
2003- 60,306
2005- 61,636
2006 62,026
2008 64,433