Railroad Medicare Cites 32.6% Error Rate for Second Quarter of FY 2017

Review Complete
Yesterday, Palmetto GBA, the Medicare Administrative Contractor for the Railroad Medicare program, announced that they have completed their widespread review of BLS Non-Emergency ambulance service claims from January through March of 2017. This comprises their announced review for the Second Quarter of their Fiscal Year 2017. 

We have more details on the review available on the news section of our site.

A total of 4,993 services were included in this claims sampling of which a startling 1,645 services were denied equating to a denial rate of 32.6% by dollar amount.

Railroad Medicare Cites 32.6% Error Rate for Second Quarter of FY 2017After all of the communications and education that the Centers for Medicare and Medicaid Services (CMS) has published, plus guidance from all of us in the industry it never ceases to amaze us regarding the continual high amount of denials resulting from these widespread reviews.

Top Denial Reasons Can Be Avoided
The leading two denials reasons were cited as “Requested Documentation Not Received” and “Insufficient Documentation.”

Let’s take a look at the first reason.

Requested Documentation Not Received
If ever there were a reason to engage someone- we suggest a third-party billing contractor like Enhanced Management Services- to watch over communications from Medicare and other payer entities it would be this reason that rises to the top of the heap. It just blows our minds in this billing office that any EMS agency fails to respond to a request for documentation from any payer source such that it causes a claim to deny.

When a claim is selected for review, the Medicare contractor sends out an ADR- Additional Documentation Request and the ambulance service then has 45 days to respond. Forty-five days is an eternity. If your EMS agency can’t locate the requested documentation and ship it out to the requestor in 45 days then something is terribly wrong with whatever system you have in place to satisfy these kinds of requests.

A staggering 740 claims were denied simply for this reason alone

For our billing office here at Enhanced Management Service, responding to any such request when they arrive in our office is routine. We archive supporting documentation digitally which can easily be cross-reference, located and shipped out to the requestor either hard copy of digitally secured (if requested digitally) to the requestor literally in a matter of minutes.

Why any ambulance service should experience a denied claim for not responding to a request for information is just ridiculous!
Insufficient Documentation
The year is 2017. It’s no secret that supporting medical necessity and reasonableness with sufficient Patient Care Report documentation is essential to the success of an ambulance billing program in today’s world.

Then, if we all know this, why is it that 760 of the denied claims in the Railroad Medicare review were denied due to insufficient documentation?

Railroad Medicare even specifically mentioned in their communication the specific reasons they cited for insufficient documentation…
  • Trip report was incomplete or omitted
  • Trip Report was for wrong date of service or wrong patient
  • The documentation was illegible
  • Trip report lacked sufficient documentation to support the medical necessity of the transport
  • If required for the type of service, the PCS (Physicians Certification Statement) was incomplete or omitted


All of the above is just basic ambulance billing 101 stuff. So, if this is basic, why is it that we in this industry still don’t get it? Again, our answer to the question is there still remains a basic lack of understanding of what it takes to do the job.

Our billing office clients, here at Enhanced, are covered. Quite frankly, if any of this is missing, we don’t create a claim in the first place. Claims are only submitted to the payer source after a thorough review of the documentation prior to creating the claim and certainly checks and balances are in place to halt the submission of a claim that hasn’t been put through rigorous review up front.

Remaining Reasons
The remaining reasons for denial were cited as non-conforming signatures of all types (90 claims)- patient, provider and healthcare providers signatures on PCS’s.

Palmetto also cited about 20 services which were rejected because the service was not reasonable and necessary.

Take the link we have provided to read the entire recap as provided by Palmetto/Railroad for a complete look at the denial reasons and their justifications for denying.

Be Ready!
Now we close this discussion with an admonition.

Be ready!

Make sure your billing office and everyone in your organization is ready for more activity because all of this extends for another 3-month period so it’s coming. What are you going to do about it?

The Ambulance Billing Services blog is brought to you as a service by Enhanced Management Services, Inc. Enhanced Management Services, Inc. is a full-service, all-EMS third-party billing contractor with Fire/EMS clients located across the United States. For more information about how Enhanced can benefit your EMS agency, please visit our website at www.enhancedms.com and click on the “Get Started” button on any landing page.

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