ALS Flycar Billing by Governments

[MerlinMedic 5]

This past Friday the Schoharie County Board of Supervisors voted to bill for ALS flycar intercepts. In Schohaire ALS is provided by the volly unit with County back -up. The County ALS is anofficial county agency, not a quasi-government agency. While I have not seen the law/resolution, I have several questions for those with a more twisted, I mean legal mind than mine:

Can government agencies bill for emergencies of any type? Gen. Municiple Law 209-c? Or other?

Can non transporting agencies bill insurance for ambulnace services?

Or, they can bill, but insurance companies will ignore the bill?

Can they only bill thru the transporting agency via some sort of a contract?

What if the transporting agency is a fire based agency that recieves tax dollars?

Any other legal dodges, I mean loopholes that I don't know of so the County can bill?

Thanx in advance your help.

[NWFDMedic 58]

Are they trying to bill the patients direct or the individual municipalities for the use of the service? Either one has bad news written all over it for the patients. Medicare and Medicaid are not going to pay for the flycar service. If the volly squads (or their townships) are getting charged for ALS intercepts, would they start making inappropriate decisions to try to get ALS as little as possible?

[Turborich 12]

More than likely the County agency has an independant contractor memorandum of understanding with the municipalities serviced stating that the municipality itself will be charged a flat or variable rate (ALS-1, ALS-2) by the County agency for services rendered.

Next month check your local Town board minutes for resolutions that outline this.

[ny10570 745]

Government agencies absolutely can bill for emergency service. Since medicaid only pays the transporting agency and most insurance companies follow the same guidelines it seems like a waste of time unless they're billing the transporting agency.

[MerlinMedic 5]

To the best of my knowedge there are no MOUs with any of the townships. Our County Board of Supervisors is the Executive & Legislative body in this county. It is made up of each town supervisor with a weighted vote based on population. No supervisor is full time. I believe they will try to bill the patient when there is no direct billing by the transporting agency. Currently, only my vollie squad bills out of 13 in the county. We use CAGs, who told the County that they would bill the ALS for them thru us & send them their portion. I was not impressed as they didn't ask us, nor offer any sort of a contract. We have summoned them to explain & have several other billing agencies waiting.

I have no problem with the County billing. I just don't want them taking my vollie squads cash. This was done so fast with no one looking too deep into the matter I think that they were sold a Bridge.

[firemoose827 324]

To the best of my knowedge there are no MOUs with any of the townships. Our County Board of Supervisors is the Executive & Legislative body in this county. It is made up of each town supervisor with a weighted vote based on population. No supervisor is full time. I believe they will try to bill the patient when there is no direct billing by the transporting agency. Currently, only my vollie squad bills out of 13 in the county. We use CAGs, who told the County that they would bill the ALS for them thru us & send them their portion. I was not impressed as they didn't ask us, nor offer any sort of a contract. We have summoned them to explain & have several other billing agencies waiting.

I have no problem with the County billing. I just don't want them taking my vollie squads cash. This was done so fast with no one looking too deep into the matter I think that they were sold a Bridge.

Come on Merlin, you and I both know it is an effort by the "County ALS" to tell the individual squads to make sure they are really needed before calling for the ALS. They stated not too long ago that their call volume was way too high...My point to them was "Yah, but you are getting paid to provide an ALS service to the people of the county, its your job. If the call numbers are too high for 2 FT Paramedics than I guess its time to hire another one?" But they dont want to hear that, they just want to get paid to teach classes now and drive around in a County Suburban with a county gas card and thousands of dollars of medical equipment that they dont want to use.

Its also an effort to get other squads to send people for their ALS training so they can provide their own service...which isnt bad, but for volunteers with 2 and 3 jobs with a family to support? Becoming ALS is a big step with a lot of additional responsibilities, who, besides a FT provider, has the time to keep it up these days? I had to give up my EMT-CC a while ago when I left FT with the ambulance I worked for, because I could not keep up with the CME requirements in just a volunteer capacity. Especially since we only did an average of 140 calls a year? How many of those are actual ALS calls?

I think that its a BS law too, they should not be billing the patient or the agency, especially since the head County ALS provider was against the idea of a volunteer agency billing patients back when we started doing so with CAG. Now here they are trying to do the same?

Merlin, send me a PM later, I have some other things to talk to you about?

[antiquefirelt 994]

Not sure how it works in NY, but Medicare says that if you bill them, your billing rules must follow their guidelines, which says you cannot bill in this manner. I think they only allow the transporting service to bill the patient, and tell you how much you can bill for BLS or ALS responses.

I say this as we started billing for ALS "Fly-car" responses about 2 years ago. We bill the service who statutorily covers where the incident happened. If we go to the town next door, they can then bill the patient for an ALS call vs. billing as a BLS run if our medic did not respond. The difference (ALS to BLS) in our Medicare area is around $130, but we bill between $225 and $275 for the run, depending on if the medic is needed or not. This forces the mutual aid EMS service to pay out of their budget, which has an added benefit of helping motivate them to hire or train to the medic level. Basically we decided our taxpayers could not afford to subsidize ALS in other towns.

[ex-commish 490]

Government agencies absolutely can bill for emergency service. Since medicaid only pays the transporting agency and most insurance companies follow the same guidelines it seems like a waste of time unless they're billing the transporting agency.

When you say govt agencies do you include fire districts or ambulance districts? I thought they could not bill.

[Turborich 12]

When you say govt agencies do you include fire districts or ambulance districts? I thought they could not bill.

Fire Districts are the only entities that can NOT bill. Ambulance Districts may bill.

[Guest]

MerlinMedic,

As I understand it a governmental body can bill for its services [revenue recovery] to offset its tax burden on taxpayers. As an ALS first responder service, a non transporting agency, it can bill medicare, medicaid, private insurance or the individual for its services but NOT for the transport portion. Regarding MOU's, the county does not have to have any agreement with an agency to bill the patient. The MOU is necessary to bill the patients insurance though. If an agency refuses to enter into an agreement withan ALS first responder agency and that agency provides a service it is now forced to bill the patient directly. In the case as you descrbed in another post that your agency currently bills and that the county would be taking money from your vollie agency that is innacurate. If the ALS service provided Paramedic care on your BLS ambulance crew, the billing company would bill the call at the ALS level and your agency would then pay the ALS service their portion of the reimbursement. As far as working with a fire district the agency in question would have to enter into what is called "bundle billing agreements". Again, if the district refuses to enter into the agreement the agency would be forced to bill the patient directly, to meet fair billing practices as dictated by medicare law.

I would like to comment on a recent post you had with moosecfd368 though. It sounds like you two are from the same area or at least familiar with the county agency written about. If I understand it right, it sounds like there are only two medics working for this service. Do they provide this service 24/7/365 ? Are they county employees? Do they provide coverage together or opposite each other? Are they paid hourly or on salary? As I figure it there are 168 hours in a week. If they are both on duty at the same time that is 168 hours each per week. If the work opposite that is 84 hours a week each. At 84 hours that is 44 hours overtime. If they are on salary that is a dedicated two-some, and I think it would be unfair to describe them as just wanting to ride around in suburbans with county gas cards as moose stated. Don't mean to stir the pot but inquiring minds just want to understand what is written in between the lines.

[MerlinMedic 5]

Watchdog, you are right, there is a lot of history between the lines, which polietness forbids me from detailing. Sufice it to say

Moose & I disagree with some other ALS providers.

To answer those questions I can: yes, 2 people are paid to provide 24/7/365 ALS in that county. They are salaried. Their choice. Local ALS providers (like myself) only practice in their vollie district or out of the county.

As to just riding around in a county flycar ... hmmm ... how to answer that? I really don't think I can. They are county employees; their own boss & do as they see fit. Med control, QA/QI is not as it is in the Hudson Valley; that much I can say. To give you an idea, I have met my vollie squads med contol doc two time in 18 years. And yes, I have set up appointments, stopped by his ER, office etc until I got the message.

[helicopper 1,050]

Watchdog, you are right, there is a lot of history between the lines, which polietness forbids me from detailing. Sufice it to say

Moose & I disagree with some other ALS providers.

To answer those questions I can: yes, 2 people are paid to provide 24/7/365 ALS in that county. They are salaried. Their choice. Local ALS providers (like myself) only practice in their vollie district or out of the county.

As to just riding around in a county flycar ... hmmm ... how to answer that? I really don't think I can. They are county employees; their own boss & do as they see fit. Med control, QA/QI is not as it is in the Hudson Valley; that much I can say. To give you an idea, I have met my vollie squads med contol doc two time in 18 years. And yes, I have set up appointments, stopped by his ER, office etc until I got the message.

I think I saw this question elsewhere, possibly in another thread, so forgive me if it is a duplicate. There are two on-duty medics 24/7 or there are only two medics in the entire service/"system"? If there are only two total, what happens if someone takes a day off or is sick?

As for medical control and knowing your doc and having the doc know you, that's pathetic. Twice in 18 years? Where do you do your call audits / CME's?

Back to the billing question - Can two different agencies bill for the same call (one ALS non-transport and one BLS transport)?

[firemoose827 324]

I think I saw this question elsewhere, possibly in another thread, so forgive me if it is a duplicate. There are two on-duty medics 24/7 or there are only two medics in the entire service/"system"? If there are only two total, what happens if someone takes a day off or is sick?

Chris, it sounds worse than it is but it still is not sufficient to cover the needs of the county; here is a brief breakdown of how ALS goes in our county.

We have 2 FT medics that are in fly cars in different parts of the county. They are on salary like merlin said, and are toned out by county dispatch. If available they sign on the radio as responding. If they take a vacation or are sick they call the dispatch and advise they are out of service, and the other coordinator takes over. Than, the second line of ALS is provided by the local Paid ambulance who has one paramedic rig in the county. If they are not available than some of the local squads have their own ALS providers, like my squad, we have one medic and several EMT-CC's now that can run on their own. AFter that...it goes down to tightening the sphincter, lighting up the lights and going like hell for the nearest appropriate facility and hope that an ALS link up with other agencies in other squads or the next county can meet us enroute. I have done a call like this years ago, with a patient having a miscarriage. She was bleeding so bad and we had no ALS. The next squad over only had an intermediate and he couldnt get a line on her, so we booked for Cooperstown Hospital and had Otsego county, to the west of us, tone out for any available ALS to meet us enroute. We picked up a medic about 15 minutes out from the ER and he got the lines.

As for medical control and knowing your doc and having the doc know you, that's pathetic. Twice in 18 years? Where do you do your call audits / CME's?

Through the County EMS Coordinators and the local CIC's and CLI's, which is than signed off by the med control doc. He is right though, some of the med control people are hard to get a hold of.

Back to the billing question - Can two different agencies bill for the same call (one ALS non-transport and one BLS transport)?

This I dont know. I was never too crazy about the whole billing thing with the volunteer agencies, plus the annual fund drive...didnt make sense to me.

[ckroll 101]

Back to the billing question - Can two different agencies bill for the same call (one ALS non-transport and one BLS transport)?

Well, anyone can bill for anything. Whether or not they will be successful is another matter. When multiple agencies provide service and each feels...and is... entitled compensation, the relationships get complicated. Occasionally mistakes get made. Indeed medicare sets the standard. There is an exception known locally as the Putnam rule as it was ostensibly written for Putnam County, New York that allows an ALS agency to bill [as a non transporting agency], if the transporting agency does not bill [a.k.a. fire rescues], and if the county is designated as rural.. and a few other things. If a county meets the criteria for the exception, then ALS could bill if the transporting agency does not. Otherwise, the ALS agency has to have a relationship with the BLS transporting agency. I can dig up references if needed.

On another point queried about counties stealing a vollies cash....not so fast. That entirely depends on how the relationship between the volunteer agency and the town is structured. If the volunteer agency is running bake sales to buy ambulances and not eating from the public trough, then they can bill and keep the money. If the volunteer agency is primarily funded by the town, either as a district or as a budget line [the description given to me was, "if the town chose another EMS provider would the volunteer agency cease to exist?" as a standard], then in point of fact, it is the town who is entitled to the money from billing, since they are the ones funding the service.

There is a fair amount of writing on the subject. How it works is that if there is a question about how to interpret a law, the office of the comptroller can be contacted by an official agency [ a town or county, not a private citizen] and a ruling about the law gets issued. These are found under opinions of the comptroller and searched for ambulance and billing. Obviously the opinion can change and it is in an agencies interest to ask again if they don't like an existing ruling.

Here is the link: http://www.osc.state.ny.us/legal/index.htm

Alternatively a town or county or ambulance corps can do whatever they want and until someone sues, it's no harm no foul.

I am no expert on the subject. Read the opinions of the comptroller and draw your own conclusions.

[ckroll 101]

Opinion 2005 - 1

This opinion represents the views of the Office of the State Comptroller at the time it was rendered. The opinion may no longer represent those views if, among other things, there have been subsequent court cases or statutory amendments that bear on the issues discussed in the opinion.

AMBULANCE SERVICE -- Fees (retention of by service provider)

CONSTITUTIONAL LAW - Gifts and Loans (collection of unpaid ambulance fees)

GENERAL MUNICIPAL LAW §122-b; STATE CONSTITUTION, ARTICLE VIII, §1: Towns may fix fees for ambulance services, to be paid by persons requesting the use of such services. Although the town, by rules and regulations, may provide for the collection of such fees by the entity providing services under contract, the fees collected belong to the town and may not be retained by the service provider for its own use. The town, by modification of the contract, may pay an additional amount to the service provider above the amount set forth in the service contract, but only in exchange for additional consideration to be provided by the service provider. To avoid contravening the constitutional gift prohibition, it is incumbent upon the town to take reasonable steps to collect unpaid ambulance fees.

This is in response to your inquiry concerning the provision of emergency medical service in a town. You indicate that the town currently contracts with a not-for profit organization for the provision of emergency medical service to town residents. Pursuant to the contract, the town pays a fixed consideration to the not-for-profit organization. The town is considering charging a fee to users for this service.

You ask: (1) whether the emergency medical services provider (the “provider”) may retain as its own monies the user fees imposed by the town for the emergency medical services; (2) if the provider is not permitted to retain the fees charged, whether the town may pay additional amounts to the provider above the amount of consideration stated in the contract; and (3) assuming the fees belong to the town, whether the town is obligated to pursue the collection of unpaid fees from users who fail to pay for ambulance services.

Section 122-b of the General Municipal Law authorizes towns to provide emergency medical service, general ambulance service or a combination of such services for the purpose of providing prehospital emergency medical treatment, or transporting sick or injured persons found within the boundaries of the town to a hospital, clinic, sanatorium or other place for treatment (General Municipal Law §122-b[1]). Under section 122-b, towns, inter alia, may contract with one or more organizations to supply, staff and equip emergency medical service or ambulance vehicles suitable for such purposes and operate such vehicles for the furnishing of prehospital emergency treatment (General Municipal Law §122-b[1][c]). Towns may fix a schedule of fees or charges to be paid by persons requesting the use of apparatus and equipment in the provision of emergency medical services or ambulance service (General Municipal Law §122-b[2]).

Further, towns may provide for the collection of the fees and charges or may formulate rules and regulations for the collection thereof by the organization furnishing services under contract (General Municipal Law §122-b[2]). Although section 122-b authorizes the town to provide, in rules and regulations, for the collection of the fees and charges by the contracting service provider, the fees, as noted, are imposed by the town and, therefore, in the absence of anything to the contrary in section 122-b, constitute town monies (see 1998 Opens St Comp No. 98-9, p 22; 34 Opens St Comp, 1978, p 204; 1975 Opens St Comp No. 75-49, unreported; 25 Opns St Comp 1969, p 90). 1

With respect to the payment by the town of additional monies to the service provider above the amount stated in the contract, we note that article VIII, §1 of the State Constitution prohibits gifts and loans of monies by towns to or in aid of any individual, or private corporation, association or undertaking. If the town were to unilaterally pay the service provider additional monies, whether derived from the user fees or otherwise, above the agreed upon amount stated in the contract, such payment, in our opinion, would constitute a mere gratuity and gift in contravention of article VIII, §1 (see, e.g., 1988 Opns St Comp No. 88-69, p 137). On the other hand, if the contract were modified so that, in exchange for paying the provider an additional amount, the town were to receive additional consideration, such as enhanced services beyond those already required under the current contract and with a value commensurate with the additional payment, the payment would not constitute a gift (see Opn 88-69, supra).

As to pursuing the collection of unpaid user fees, there is case law indicating that the failure to seek recoupment of monies owed to a municipality may constitute a gift in contravention of article VIII, §1 (see, e.g. Oneida County v Estate of John A. Kennedy, 189 Misc 2d 689, 734 NYS2d 402; Nance v Town of Oyster Bay, 41 Misc 2d 446, 244 NYS2d 916, mod on other grounds, 23 AD2d 9, 258 NYS2d 156; see also 1978 Opns St Comp No. 78-684, unreported). Therefore, to avoid contravening the constitutional gift prohibition, we believe it is incumbent upon the town to take reasonable steps to seek recoupment of unpaid ambulance fees. What constitutes a reasonable step may vary from case to case. In general, however, collection efforts may include, as appropriate, sending dunning letters2, imposition of a lien on real property (see Municipal Home Rule Law §10 [1][a][ii][9-a])3 and commencement of civil actions. We also believe that in determining how to proceed, the town may take into consideration an analysis of the costs involved, as well as whether a given claim may be uncollectible as a practical or legal matter, such as when a claim is barred by the statute of limitations, or in the case of bankruptcy or lack of attachable assets (see Opn No. 78-684, supra).

Accordingly, towns may fix fees for ambulance services, to be paid by persons requesting the use of such services. Although the town, by rules and regulations, may provide for the collection of such fees by the entity providing services under contract, the fees collected belong to the town and may not be retained by the service provider for its own use. The town, by modification of the contract, may pay an additional amount to the service provider above the amount set forth in the service contract, but only in exchange for additional consideration to be provided by the service provider. To avoid contravening the constitutional gift prohibition, it is incumbent upon the town to take reasonable steps to collect unpaid ambulance fees.

February 15, 2005

Jeffrey A. Siegel, Esq., Town Attorney

Town of Duanesburg

[MerlinMedic 5]

Ckroll, thanx for the info. Moose also described our local, hill billy ALS fairly well.