Medicaid Billing For Schools in 2019

In the state of Massachusetts, the Medicaid program is administered by MassHealth, which works jointly with the School-Based Medicaid Program (SBMP), and is administered by the University of Massachusetts Medical School (UMMS).

Program Overview

In the state of Massachusetts, school children can be enrolled in the Medicaid program, so as to have access to benefits which are made available to them through state and federal funding. Matching funds from the Federal Financial Participation program are made available to participating LEA’s who are members of the school-based Medicaid program. Reimbursement for SBMP services and for the administration of activities is based on allowable costs which are incurred by the LEA’s.

When a claim is made through MassHealth, the state is authorized to pass along that claim so as to receive federal funding for administrative activities and direct services, which have previously been approved by the Centers for Medicare and Medicaid (CMS). There are three major components to the SBMP, which includes direct service claims submitted to MassHealth, administrative activities claims, and the Random Moment Time Study, each of which will be explained in detail below.

Direct Service Claiming

The program known as Direct Service Claiming (DSC) provides a channel through which LEA’s can seek federal reimbursement for Medicaid provided services delivered in their schools. These type of direct medical services include physical and occupational therapies, speech therapies, counseling of a psychological nature, audiology services, skilled nursing, personal care services, and therapy services considered to be in the arena of Applied Behavior Analysis (ABA).

Up until July 1, 2019 any of these services covered by Medicaid can only be reimbursed when they are provided in concordance with a student’s Individualized Education Plan (IEP). After July 1, the program will be expanded to include reimbursement for all services covered under Medicaid, even without the IEP accompaniment.

This will now include such additional services as behavioral health screenings, fluoride varnish treatments, and many other services which are ordered by a physician, a nurse practitioner, or a physician assistant, as deemed medically necessary. When the fiscal year concludes on June 30, all LEA’s are required to submit a Cost Report which details the total allowable costs incurred by the LEA during the previous fiscal year. This Gross Medicaid Reimbursable Amount report must necessarily be submitted with a certification which verifies the accuracy of all claims listed on the report.

Administrative Activities claims

The program identified as the Administrative Activities Claiming (AAC) program works to reimburse government agencies for allowable costs related to Medicaid administrative functions. Reimbursement for the AAC element of SBMP services centers around allowable incurred Medicaid costs which are related to the execution of Medicaid administration activities, as described by the Random Moment Time Study (RMTS).

All these expenditures are detailed quarterly, under the administrative claim made in the Massachusetts School Based Medicaid program. Examples of the allowable administrative expenditures which would be reimbursed under the program include all of the following:

  • transportation expenditures of a specialized nature
  • tuition expenditures which are out of district
  • supply and material costs which are supporting Medicaid administrative activities
  • employer paid benefits and staff salary expenditures
  • capital costs which are derived by applying a pre-set capital percentage allocation rate
  • indirect costs derived by applying a DESE indirect cost rate.

Random Moment Time Study

In order to quantify the actual portion of reimbursable staff time claimed through direct service claims and administrative activity claims, the method known as the Random Moment Time Study is imposed. At random moments through the entire school year, LEA staff time is sampled by having pool respondents provide answers to questions about what they were doing at a specific random moment in time. After compiling statewide results from these responses, the methodology then generates a statistically valid proportion of reimbursable time for each of the respondent pools participating in the survey.

This entire process is carried out online using the Massachusetts RMTS system, and is designed to be as quick and unobtrusive as possible. The results of the statewide RMTS survey are combined with costs relative to each provider, and are then submitted in an annual cost report, so as to determine the level of reimbursement appropriate for Direct Service Claiming, as well as for Administrative Activity Claims.

SBMP and MassHealth

MassHealth is the agency that oversees the School-Based Medicaid Program in Massachusetts. The organization develops policies as well as ensures that schools are in compliance with federal and state regulations for the Medicaid program. The University of Massachusetts Medical School works with MassHealth to administer SBMP. LEAs must seek reimbursement through MassHealth. The contracting process begins through the MassHealth Provider Enrollment Center.


While there is currently a requirement that direct services be through an IEP, this requirement will be lifted beginning July 1, 2019. In addition, additional provider types and services will be added through an effort called Expansion. The goal of the Expansion is to broaden the program and to provide services for students that may not be associated with an IEP. Specifically, services will be covered if they are part of a section 504 plan, an individual health care plan (IHCP), an individualized family service plan (IFSP), any state-mandated screenings, and some services deemed medically appropriate. This broadens access to reimbursement significantly to include nutritionists, school psychologists, respiratory therapists, dental hygienists, and other health care professionals working through educational institutions. The four pools of services acceptable under the Expansion are medical services, therapy services, behavioral/mental health services, and administrative services.

To help make this transition easier, the SBMP will offer trainings as well as updated website information and documents in the SBMP Resource Center.

Training programs include:

  • RMTS
  • Cost Report
  • Administrative Claiming
  • Interim Claiming

Training dates will be made available to LEAs.

Program guides will be made available for:

  • RMTS User Guide
  • SBMP Administrative Claims Instruction Guide
  • Massachusetts School-Based Cost Report Instruction Guide
  • SBMP User Guide
  • Procedure codes and interim rate bulletin for providers

Challenges to keep in mind

There is a difference between a covered service and a reimbursable service. Even though a service may be included in what is covered and reimbursed, there are requirements that must be met in order for reimbursement to take place. Along with factors like parental consent, a reimbursable service must be part of the direct service pool and documented correctly. If a service does not meet reimbursement requirements, even if it is covered under the program, it will not be reimbursed.

Parental consent is needed for the service in order for it to be reimbursable. In alignment with federal law as well as the Department of Elementary and Secondary Education’s (DESE’s) student records regulations, parental consent is required for reimbursement. LEAs should only submit claims for MassHealth-enrolled students after parental consent has been obtained. In addition, only students from whom parental consent has been obtained should be included in Medicaid eligibility statistics. A sample parental consent form can be found on DESE’s website. The link for the sample form can also be obtained from MassHealth.

LEAs are directly involved in the process. Updated contact requirements mean that LEAs are involved in most processes rather than relying on billing vendors. It is the LEAs who are the contracted provider. It’s important to remember that LEAs are the entities audited by agencies like MassHealth.

Medicaid Billing For Schools in 20192019-06-19T16:24:33+00:00

5 Things You Need to Know About the MassHealth School-Based Medicaid Program

The MassHealth School-Based Medicaid program (SBMP) affords an opportunity for local education agencies to be awarded with federal money that will help to offset the costs for schools which have to provide specific Medicaid-covered services to students. MassHealth is the governing body which oversees SBMP, and which ensures compliance with laws enacted by state and federal agencies. The entire program is administered by the University of Massachusetts Medical School (UMMS), on behalf of MassHealth, and this has been true since the program began in 1994. Here are some of the most important things to know about this School-Based Medicaid Program.

How local education agencies (LEA’s) are reimbursed

Reimbursement for local education agencies is based on actual cost, so that these LEA’s can seek reimbursement for direct health services through the process of Direct Service Claiming (DSC). Specific administrative expenses can also be claimed if they’re associated with providing medical services, or with assisting students in becoming enrolled in MassHealth, via the administrative activity function.

At the present time, the only health services which are covered are those which are pursuant to an IEP, although this will change as of July 1, 2019. At that time the requirement will be lifted, and other services as well as additional provider types will be included. In the world of SBMP, this July 1 amendment is referred to as Expansion.

Random moment time study (RMTS)

The random moment time study is a program which aids MassHealth in determining how educational staff members spend their time, and the results of this time study have a major impact on local education agency reimbursement. Any LEA seeking reimbursement through AAC or DSC must be included in an RMTS pool, so that MassHealth can gain an understanding of where time is being spent by staff members.

Throughout the school year, educators are queried about exactly what they were doing at a specific moment in time, and are given two school days to respond to that query. This methodology has proven to be statistically valid in estimating the amount of time that educators spend across the state, performing various types of work activities relevant to the pools that they’re in.

Pools for random moment time study

All educators associated with local education agencies seeking reimbursement through AAC or DSC must belong to one of the specified RMTS pools, since admin reimbursement must be claimed for all participants of the RMTS program. Staff members are allowed to change RMTS pools each quarter, unless you are a staff member who is federally funded, or who is part of the indirect cost rate program.

At present, there are three distinct RMTS pools, consisting of ABA Therapy, Administrative, and Direct Services. When Expansion comes into play on July 1, there will be four RMTS pools, and these will be comprised of Administrative, Medical Services, Therapy Services, and Mental/Behavioral Health. Staff members who are in the Direct Service pools can have their costs claimed by the appropriate LEA when those costs are associated with either Direct Service or Administrative Activities.

Staff members included in Direct Services

Each staff member involved with an LEA must be considered individually, rather than in any grouping which is based on job title or job description. That means LEA’s are allowed to include in their Direct Service Pool any staff members who are associated with the following services:

  • speech or language therapists
  • Medicaid billing personnel
  • social workers
  • psychologists
  • psychiatrists
  • applied behavior analysts
  • audiologists and audiology assistants
  • counselors
  • occupational therapists and assistant occupational therapists
  • physical therapists and assistant physical therapists
  • personal care service providers
  • nurses, either LPNs or RNs
  • autism specialists.

Reimbursable Administrative Activities

There are a number of reimbursable Administrative Activities, beginning with what’s considered to be an outreach function, involving the information of potentially eligible families about MassHealth and how it should be accessed. Assistance with the application for MassHealth is also a reimbursable administrative activity, as is any activity which helps to develop strategies that improve delivery of covered services. Such activities include collaborative efforts with other agencies relative to health services.

Another reimbursable activity is setting up referrals for health service, or coordinating and monitoring the delivery of Covered Services. Helping an individual to obtain transportation through MassHealth is reimbursable, as are translation services when they are needed in order to access health-related services. Finally, any activity which provides staff training at an LEA which is related to Medicaid topics is also a reimbursable activity.

For a free consultation or to talk to a MassHealth School-Based Medicaid expert please contact us.

5 Things You Need to Know About the MassHealth School-Based Medicaid Program2019-04-25T16:17:47+00:00

School-Based Medicaid Program Expansion in Massachusetts – What You Should Know

The School-Based Medicaid Program (SBMP) provides an opportunity for local education agencies (LEA’s) to be reimbursed by the federal government for the coverage of costs associated with providing specific services covered by Medicaid in a school environment. Local education agencies  can include public, vocational or technical schools, regional school districts, and charter schools.

The SBMP program is directly administered by MassHealth, which not only oversees the program, but also develops any new policies, and is responsible for ensuring compliance with all state and federal regulations and laws. In cooperation with MassHealth, the University of Massachusetts Medical School oversees the School-Based Medicaid Program, to ensure that program directives are carried out in all areas of the state.

Reimbursement under the School-Based Medicaid Program

Any LEA which is considering becoming involved or is already involved in the program would be well advised to review information available from the Resource Center, or contact School Based Claiming at 1-800-535-6741 option #0, so they can learn more about the program. The SBMP provides a contact information page on its website to facilitate all queries of this nature.

Up to and including the date of June 30, 2019, any claims made under SBMP must be identified as reimbursable, according to an individualized education plan (IEP) established with a specific learning institution. As of July 1, 2019, that IEP requirement will change, so that a number of additional services and provider types can then be considered valid as well. This changeover of IEP requirements has been termed Medicaid Expansion Program.

Impact of Expansion

The major thrust of Expansion by MassHealth is to broaden the School-Based Medicaid Program, so as to also include payment for medical services given to students under different plans besides the IEP. In addition to covering services pursuant to an IEP, the Expansion program will now also cover services pursuant to an individual health care plan (IHCP), a section 504 plan, and individualized family service plan (IFSP), state mandated screenings, and even some services which are simply deemed medically appropriate.  

The practical effect of Expansion means that it will now be possible to claim reimbursement for medical services offered by a dental hygienist, a nutritionist, a respiratory therapist, a school psychologist, and several other medical professionals in residence or contract at learning institutions. As of July 1, 2019, there will be four acceptable pools for services provided under the School-Based Medicaid Program. These four include medical services, therapy services mental or behavioral health services, and administrative services. LEA’s will be required to implement all amendments necessary to provider contracts with MassHealth, in order to continue their involvement with the School-Based Medicaid program, even if they only intend to make claims for IEP services. To prepare LEA’s for Expansion, a number of training and guidance tools have been made available by MassHealth, so as to ensure a smooth changeover.

School-Based Medicaid Program Expansion in Massachusetts – What You Should Know2019-03-14T14:45:13+00:00

How Will the ET3 Model be Phased Over the Next Several Years, to Make it Easier for Providers to Deliver High-quality Service?

In February of 2019, the U.S. Department of Health and Human Services (HHS) announced a new model to be used for payment of emergency ambulance services. This new model is intended to allow Medicare fee-for-service beneficiaries to get the best level of care at the time and place required, while also providing the possibility of reducing out-of-pocket costs.

The model has been dubbed the Emergency Triage Treat and Transport system (ET3), and it aims to make it much easier for participating ambulance providers to team up with qualified healthcare personnel, so as to deliver treatment, either on-location or at an alternative destination. On-site treatment can be delivered either at the specific location or via telehealth procedures, and the alternative destinations can be either physicians’ offices or urgent care facilities. The specific instances where the ET3 model would apply are those pertaining to Medicare patients during a medical emergency involving 911 services.

Benefits of the ET3 Model payment system

Those ambulance service providers who are able to achieve some important quality metrics with superior performance will be eligible to receive up to 5% adjustment in their payment rates. This should encourage overall excellent performance among providers, since the  adjustment can be considered to be a significant incentive.

The medical personnel at destination facilities would not be affected by these payment adjustments, receiving their normal reimbursement, but would theoretically benefit by working with the better-performing ambulance providers, in terms of increased traffic. The intent of the quality measures is to prevent any additional burden on participants, particularly in the area of reporting requirements associated with providing care for patients.

How ET3 will be phased in

Since this program must be implemented across the entire U.S., it will take some time before it can be fully implemented. Recognizing this, the originators of the new model have determined that a phased approach is best, in terms of putting the new payment system in place. Part of the reason for this is to avoid discouraging potential participants of the program from having to do too much all at once, and the gradual implementation seems best suited to accomplish this goal.

Maximum participation in the program will be encouraged by ensuring access to model usage in all regions of the country, and by promoting the potential for ambulance providers to team up with other insurance carriers, particularly state Medicaid agencies. A series of application rounds is expected to be used in order to phase in each of the different aspects of the program, beginning with the issuance of a Request for Applications form in the summer of 2019.

This form will seek to discover all eligible those ambulance providers who are enrolled with the Medicare system, and to solicit their participation in the program. A follow-up phase which is scheduled for the fall of 2019 will see the Center for Medicare and Medicaid Services (CMS) issuing a Notice of Funding Opportunity for the purpose of establishing a number of two-year cooperative agreements with local governments and other agencies.

These agreements would be for all bodies which have the authority to answer 911 calls and dispatch Medicare-enrolled ambulance services to handle those calls. This phase of implementation addresses low-acuity 911 calls, in other words, calls where there is no immediate life-threatening situation in progress that must be dealt with. It is anticipated that high-acuity 911 calls would then be addressed at some point in the following year, in the next phase of implementation.

How Will the ET3 Model be Phased Over the Next Several Years, to Make it Easier for Providers to Deliver High-quality Service?2019-03-04T16:46:28+00:00

Ambulance Billing Guide for 2019

All cities throughout the New England area are faced with the need to conserve on expenditures and to provide the most value for services which have been budgeted, and ambulance service is no exception. Since ambulance service is so critical to the community and those individuals in need of emergency transportation to the hospital, ambulance billing is an area that must be carefully considered and budgeted for 2019 and beyond. With that in mind, the following guide is offered, so that the various municipalities of the New England area may properly plan for accurate ambulance billing in the coming year.

Annual Inflation Factor (AIF)

Section 1834 of the Social Security Act states that each year the fee schedule for ambulance billing must be increased so as to include the cost of inflation, and this figure is referred to as the Annual Inflation Factor. This factor is arrived at by calculating the consumer price index for all urban residents for the preceding year, ending in June.

For the year 2019, the AIF has been calculated to be approximately 2.4%, which means that all ambulance fees for 2018 would automatically undergo an increase of 2.4% for 2019. While this may not be the only factor which is applied to ambulance pricing in New England, it is the base entitlement for pricing, according to the federal government. Any local considerations would have to be added in to this figure, in order to arrive at the appropriate billing figure for a given area.

Ambulance billing services provided by New England Medical Billing

With a better than 95% collection rate, New England Medical Billing ranks very highly in yielding a high return on investment for services provided.  With highly trained and knowledgeable staff members, collections are done efficiently and promptly, while personal injury protection benefits are still available. A partial listing of the services provided by NEMB for 2019 will include all the following:

  • Coding Services – Our staff has a number of certified coders , so that accurate and timely billing can be carried out, with minimum chance for costly denials.
  • Documentation reviews – NEMB specialists conduct  reviews of documentation and offer critical feedback to providers. When documentation is inadequate, this is pointed out so it can be rectified.
  • Detailed Analysis and Reporting – Clients of New England Medical Billing have access to a whole range of reports to obtain critical information. There are financial reports, weekly deposit reports, cost projection reports, payments by payer, and fee schedule analyses, among others. All of these reports can be fully customized to accommodate clients’ needs for use as management tools. In addition to prepared reports, our expansive database can be accessed to prepare ad-hoc reports which will help any municipality improve on its business practices.
  • Ongoing support – Every community requires a fully functional and prompt ambulance service, as well as the billing support which makes all those services a reality.  NEMB prides itself on making available to clients all the advice and support needed to answer all questions, and to develop an effective billing strategy founded on outstanding communication.
  • Accounts Receivable Management – Clients’ accounts can be reconciled monthly, and all files and documentation are maintained by NEMB so as to stay in compliance with any municipal requirements regarding the subject. Data is backed up regularly, so that there will be no catastrophic loss of information should an accident occur. All accounts receivable information is managed and maintained in a highly efficient manner by our trained specialists.
  • Confirmation of Patient Eligibility – Before any medical billing is executed, NEMB ensures that patients are eligible, especially in the area of auto accident claims. Because paramedics are more concerned with life-threatening services than with capturing all the relevant motor vehicle insurance data, we go the extra mile to verify all that. Our personnel will contact the appropriate Police Department or Fire Department to obtain accurate information before any billing is carried out. Everything which is necessary to ensure a clean claim on the first attempt is addressed by our specialists, so that billing can be done smoothly and efficiently, with minimal denials.
  • Front-end training – All of our clients have access to coding and documentation information, so that critical personnel can be informed about appropriate procedures and codes, which they can then use in the performance of their daily jobs.
  • Preparation of Abatement Lists – Our trained specialists are well-versed in the preparation of Abatement Lists, and can document all the processes associated with the ongoing compilation of these lists. That includes verifying, retaining, and providing advice on the entire documentation process.
Ambulance Billing Guide for 20192019-03-04T16:48:48+00:00

Which School Health Services are Covered by State Medicaid?

Children who are covered by Medicaid receive affordable and comprehensive health care coverage, to allow them to continue academic pursuits and become successful as adults. More than 30 million young people are currently receiving benefits under this program, and research has demonstrated clearly that this assistance makes a big impact on their future, as well as helping them deal with current medical conditions.

Services covered by state Medicaid

Probably the single most important area of coverage for eligible children is providing the medical services needed by children with disabilities, so they can receive a good education. The goal of these services is to allow disabled children to be educated in the least restrictive environment possible, given their specific disabilities. However, this is far from the only area of coverage supported by Medicaid. All children who are eligible can receive such health services as dental and vision screenings, to ensure that basic health needs are being attended to.

Some of the other specific services which participating schools can be reimbursed for under state plans for Medicaid are the following:

  • Nursing services
  • Mental health services
  • Audiology services
  • Physical therapy
  • Speech therapy
  • Nutritional assessments and counseling
  • Transportation
  • Facilitating of determination for Medicaid eligibility
  • Coordinating and monitoring Medicaid services
  • Providing transportation to Medicaid-covered activities
  • Making referrals
  • Medical service program planning
  • Positive effects of Medicaid coverage

    A significant amount of study and research have gone into determining the impact of Medicaid on students who receive coverage while in school. Quite naturally, the government agencies who contribute the funding for state Medicaid are anxious to know that the funding is having a positive impact, and is accomplishing what the program is intended to do. Statistics compiled on this subject are uniformly positive about the huge impact Medicaid coverage has on students in school and long afterward, when they reach adulthood.

    Research has shown that children covered by Medicaid in school retain better health as adults, with fewer trips to the hospital and fewer visits to the emergency room. Medicaid-eligible children have also shown that they are more likely to graduate from high school or college, earn bigger salaries, and pay more taxes than students who receive no Medicaid coverage due to ineligibility.

    It is also reported that virtually all school districts benefit from the funding they receive for Medicaid-covered services because those funds can be applied to health services administered to all students enrolled, not just those receiving Medicaid services. In a survey recently conducted, almost half of all school superintendents indicated that they used Medicaid reimbursement funds to pay for general school supplies and health services, which all students benefit from. These general health care services include such critical areas as monitoring and caring for children with asthma or diabetes, as well as providing limited dental care.

    One last service provided by many schools in this country is to serve as a kind of gateway for children in low-income families, by helping to get them enrolled in Medicaid and the Children’s Health Insurance Program (CHIP). The importance of Medicaid funding for schools would be hard to overestimate, given the fact that even for services which are not covered under Medicaid, the funding allows schools to reach out and connect children with services needed outside of school, and outside the Medicaid program itself.
Which School Health Services are Covered by State Medicaid?2018-12-20T15:43:44+00:00

Top 5 Urgent Care Billing Tips

Because of the number of steps involved in the claims creation process, it’s very common for there to be some mishaps in urgent care billing. For that reason, it becomes very easy for clinics and health facilities to be underpaid for urgent care services. To avoid this possibility, consider the five most important urgent care billing tips identified below.

Establish your contracts

If your clinic does not have its contracts properly established with the local payers for medical services, you have little hope of being paid on time or in the proper amounts. You should have all these contracts in place before you even open your clinic ideally, so that you’re not negotiating while waiting to be paid for claims. If you are obliged to negotiate contracts, you won’t be able to accept patients’ insurance coverage, and that means you’ll only be able to operate on a cash-only basis – which means you’ll have very few patients.

Use good front-desk practices

Front-desk personnel should be trained to check the current insurance for every patient, rather than asking if anything has changed since their last visit. This can help eliminate some improperly filed claims, for instance those with inaccurate demographics, addresses, or insurance numbers. When anything is submitted to a payer which is not accurate, it can result in having to re-submit, or having the claim denied altogether because it was sent to the wrong payer. It’s also a good idea to have your front-desk personnel audit denied claims periodically, to see if there are any trends associated with those denials.

Don’t overlook valuable charges

In the day-to-day hectic pace of a medical facility, it can be very easy to overlook some valuable charges, and therefore miss out on an entitled payment. Some of the most common oversights are injections, X-rays, blood draws, lab work, and reading of results. The volume of drugs dispensed is another area of fairly common oversight, and thus underpayment. Make sure your staff has been trained to identify and include these frequently missed charges, so you don’t end up providing free services.

Make sure to use the right billing codes

Choosing a lower-level 2 or 3 code might seem to be just right when billing charges are being coded, but higher-level codes are often justified and should be used in those cases. Your medical practice could be losing a significant amount of money daily by underestimating the code levels on charges. In addition, the American Medical Association regularly updates codes, and there have recently been thousands of new codes added to the compendium of charges. Make sure your office personnel are aware of these new codes, and that the correct ones are used during billing.

Use the correct code modifiers

Code modifiers help to identify the service which was delivered to a patient, and they provide additional information beyond the base code on any given charge. Although code modifiers are often essential for identifying just what kind of service was administered, these modifiers are often overlooked entirely or misused, thereby conveying an inaccurate picture of the service which was delivered. Make sure your staff are well-versed in using these code modifiers, and that they have a good understanding of which code modifiers are accepted by all payers.

Top 5 Urgent Care Billing Tips2019-01-02T17:52:43+00:00

Demographic information critical for ambulance billing success

Even in an ideal scenario, it’s difficult to capture complete and accurate demographic information. There are typos and misspellings with which one must contend, and patients don’t always provide correct data. Now consider an emergent situation in which a patient requiring ambulance transportation may not even be conscious. At times, it’s nearly impossible for paramedics and emergency medical technicians (EMT) to capture simple details such as a name or date of birth. Saving the patient’s life and rushing him or her to the closest hospital is the number one priority.

Hopefully, the patient receives the care that he or she needs in a timely manner. However, when it’s time to submit the claim for ambulance services, many municipalities discover that they don’t have enough information or the right information. Designating these claims as ‘self pay’ is not an optimal solution because the reimbursement rate is oftentimes much lower for self-pay than it is for fee-for-service. If a municipality tries to submit a claim with demographic errors and omissions directly to the insurance company, there’s a high probability that it will be denied.


Obtaining demographic information through collaboration

Best practice is for billing vendors working on behalf of municipalities to establish relationships with local hospitals and create information technology (IT) integration with hospital health information systems to obtain complete and accurate demographic and insurance information for billing purposes. This ensures that there are no information gaps and that patients are billed directly only as a last resort.

It takes time and effort to cultivate these relationships. However, once these relationships are established via personal and IT connections, it’s much easier for a billing vendor to obtain information necessary for claims submission. This includes the patient’s full name, date of birth, address, phone number, Social Security Number, and insurance identification number.

What must occur from an IT perspective to enable integration? Fundamentally, your billing vendor must be willing to take the time to reach out to a hospital’s patient accounting and IT departments. Consider asking these three questions of your vendor:

  • Does your billing vendor work closely with hospital IT systems to obtain accurate and complete demographic information?
  • Does your billing vendor have the ability to integrate with hospital demographic systems using HL7 or other types of interfaces?
  • Does your billing vendor have established relationships with hospitals?


Ensuring compliance through documentation

It’s also important for paramedics and EMTs to document the nature of the beneficiary’s medical condition at the time of transport. Medicare pays for emergency and non-emergency medical services when the beneficiary’s condition is such that other means of transportation would endanger him or her. In its FY 2017 Work Plan, the Office of Inspector General (OIG) is taking a closer look at whether Medicare payments for ambulances services were warranted.


Other strategies to capture demographic information

Following are three other ways in which paramedics and EMTs can obtain much-needed demographic information at the time of transport:

  1. Ask a loved one for demographic information before or during the transport itself.
  2. Obtain information from the hospital emergency department at the time of transport.
  3. Verify existing demographic when there is a repeat transport.

To learn more about our billing programs, contact Nancy Dolgin at NEMB at 508-297-2068 x232.


About NEMB

NEMB understands the importance of building meaningful relationships with entities and individuals within each municipality so we can ensure timely and compliant billing. Not only do we communicate regularly with fire and police departments, but we also take the time to get to know and network directly with town accountants, town managers, mayors, and others. We identify the key individuals within each municipality who can provide the critical information we need to bill ambulance services appropriately and as quickly as possible.

With nearly 20 years of experience in municipal ambulance billing, our credentialed staff members are trained in every aspect of effective municipal service billing. We specialize in auto accident claims that continue to challenge municipalities and result in significant revenue lost. We pursue auto accident claims as quickly as possible so our clients can take advantage of personal injury protection benefits before those benefits are depleted. Our expertise and focus on communication and relationship building help to maximize cash flow and ensure the fastest possible return on investment for the services provided. NEMB’s ambulance billing record has consistently yielded over a 90% collection rate.


Demographic information critical for ambulance billing success2019-01-02T17:52:47+00:00

CMS rule reversal for Medicaid free care: Will additional reimbursement be on the way for Massachusetts public schools?

Massachusetts public schools participating in school-based Medicaid claiming may soon see a revenue boost thanks to a CMS reversal of its long-standing Medicaid free care rule. This surprising reversal essentially allows schools to bill Medicaid-covered services for all students—even when those students don’t have a documented Individualized Education Plan (IEP).

In a letter to state Medicaid directors dated December 15, 2014, CMS formally withdrew its prior guidance on the free care policy with the goal of being able “to facilitate and improve access to quality healthcare services and improve the health of communities.”

These developments come in the wake of two other states—California and Oklahoma—successfully challenging the free care rule that had, for years, stated that schools may not use Medicaid funds to pay for covered services that are provided for free to the entire student population.

Both states successfully argued that this rule was not based on federal statute. However, many states—including Massachusetts—have continued to apply the rule due to a lack of technical guidance as well as confusion over whether schools nationwide—or only those in California and Oklahoma—could qualify for federal reimbursement.

In its 2014 letter, the agency goes on to state the following:

Under this guidance, Medicaid reimbursement is available for covered services under the approved state plan that are provided to Medicaid beneficiaries, regardless of whether there is any charge for the service to the beneficiary or the community at large. As a result, Federal Financial Participation (FFP) is available for Medicaid payments for care provided through providers that do not charge individuals for the service, as long as all other Medicaid requirements are met.

States nationwide are slowly coming on board to follow in the footsteps of California and Oklahoma. Massachusetts, for example, may announce statewide changes as soon as October. Once schools are able to expand Medicaid billing for all students, they could see a significant increase in reimbursement—particularly related to nursing services. According to, health advocates see this policy change as an opportunity to develop programs in public schools to help students understand and manage chronic conditions such as asthma, diabetes, and mental illness. In some cases, the additional reimbursement may also be able to help schools hire more nurses. According to the National Association of School Nurses, more than 30% of schools only have a part-time nurse, continuing to drive a school nursing shortage nationwide.

Medicaid-covered services include speech therapy, occupational therapy, physical therapy, audiology services, counseling, nursing services, personal care, behavioral health, and applied behavior analysis.

What can your school do now to prepare for potential changes? Consider these tips:

  1. Review all of your vendor’s services. Does your vendor have experience in school-based Medicaid claiming along with compliance for HIPAA and the Family Educational Rights and Privacy Act (FERPA)? If you haven’t done so already, you’ll need to find a vendor that understands the Medicaid program and all of its requirements. 
  1. Think ‘data integration.’ To bill for a potentially increased volume of Medicaid-covered services, schools must ensure that their billing vendor can streamline the process as much as possible. Has your vendor initiated meetings with various stakeholders to streamline data flow within the school nursing office along with other school departments? Or must the school absorb additional costs to enable that interoperability?
  1. Ensure that documentation is meeting standards. Schools will only receive additional reimbursement when all documentation and billing requirements are met. Specifically, documentation must include the following elements: School district name/provider number, provider credentials, student name, student date of birth, student Medicaid number, date of service, activity/procedure note (including whether the activity/procedure was performed individually or as part of a group), service time, and signatures. Note that thorough and complete documentation also mitigates the risk of a third-party audit.
  1. Seek out resources. For up-to-date information about school-based Medicaid billing, refer to the National Alliance for Medicaid in Education, Inc. (NAME). To learn more about compliant Public School-Based Medicaid Claiming, call Jennifer White at NEMB at 508-297-2068 x233.


About NEMB

New England Medical Billing is a leader in School-based Medicaid claiming and administration. We are a fully HIPAA-compliant Medical Billing Management and Administrative Service Firm. Our expertise is in program and system design as well as effective implementation and administration. Our multi-disciplinary approach and attention to detail consistently yields the maximum allowable returns on every client project.

Since 1993 NEMB has been built carefully, approaching each new engagement using proven management methods. Our superior, time-tested approach is applied to each and every engagement. We “zero-base” every new proposal to build a process that fulfills the unique requirements and goals of each project.

Our billing administration experience in ambulance & EMS services, emergency departments, school-based Medicaid claiming and private physician practices has honed and streamlined our clients’ operations in capturing and maximizing revenue opportunities on a large scale.

CMS rule reversal for Medicaid free care: Will additional reimbursement be on the way for Massachusetts public schools?2019-01-02T17:52:50+00:00

Community paramedicine on the rise

More than 75 million people live in rural (or partially rural) parts of the country that the federal government has designated as healthcare shortage areas, according to the most recent data from HHS. This means individuals in these areas may not have access to valuable healthcare services when and where they need those services the most. In addition, many emergency medical services (EMS) providers often respond to non-emergent situations. As a result, some states have begun to consider alternative solutions to bridge the care gap and reconsider the role of the EMS provider. Community paramedicine—a model of care that expands the role of EMS providers to meet healthcare demands—is one example.

What exactly is community paramedicine?

According to the Joint Committee on Rural Emergency Care (JCREC), community paramedicine “increases patient access to primary and preventive care, provides wellness interventions within the medical home model, decreases emergency department utilization, saves healthcare dollars, and improves patient outcomes.” It essentially allows paramedics to apply their training and skills beyond the traditional emergency response and transport model to expand the reach of primary care and public health services.

Various community paramedicine pilot programs have emerged nationwide as a way to address the Institute for Healthcare Improvement’s triple aim—that is, to decrease healthcare costs, improve health outcomes, and improve the patient experience. The industry may continue to see an increased focus on community paramedicine commensurate with the shift toward Accountable Care Organizations, value-based purchasing, and bundled payment models. That’s because in a community paramedicine model, EMS personnel work as part of the overall care team to deliver low-cost, high-quality, coordinated care.

For example, in 2012, Maine lawmakers removed regulatory barriers by authorizing up to 12 community paramedicine pilot programs throughout the state. Other similar programs have been initiated in Minnesota, Colorado, and Texas.

In Massachusetts, the Commonwealth Care Alliance (CCA)—a non-profit, pre-paid care delivery system for low-income and elderly or disabled beneficiaries—partnered with EasCare Ambulance, LLC to develop an Acute Community Care (ACC) model that relies heavily on community paramedicine. During the first 18 months of the ACC program, paramedics responded to almost 600 dispatches for the urgent care needs of more than 200 unique members. This model has been particularly helpful with these distinct clinical needs: members with urinary tract infections (UTIs), altered mental status/behavioral health conditions, respiratory distress, complex physical disability, and members nearing the end of their lives and engaged in CCA’s palliative care program.

However, to be successful, community paramedicine programs must foster collaboration among local stakeholders, including residents, elected officials, clinic and hospital administrators, and colleges/universities. This collaboration includes identifying best practices for funding community paramedicine programs. To date, many of these programs are supported through public and private grants. In addition, several CMS Healthcare Innovation Grant awardees receive Medicare fee-for-service for community paramedic services.

In Maine, municipal-based EMS agencies received funding for community paramedicine pilot programs as part of their regular EMS budget from the towns in which they were located. One private, nonprofit EMS provider requested a subsidy from its town. Ambulance services that were hospital-owned relied on the hospitals to absorb some or most of the cost of providing the community paramedic service.

Billing for community paramedic services also poses a challenge, as these programs must define a structure that works well for their individual needs. For example, the Minnesota Community Paramedics program sets forth various billing and documentation guidelines with the goal of tying services provided by a community paramedic directly to a physician. South Carolina follows a similar billing protocol.

Interested in learning more about community paramedicine? Consider these tips:

  1. Read up on resources. In 2012, the Office of Rural Health Policy published the Community Paramedicine Evaluation Tool to help communities establish a common framework for measuring outcomes and capturing data, both of which are a necessary part of competing for federal and state grants. The tool also helps communities assess needs and build partnerships to support a community paramedic program.
  2. Partner with the right billing vendor. Look for a vendor with a diverse background in billing for EMS, urgent care, and home care.
  3. Contact other community paramedicine programs. Inquire about the structure of the programs and how they overcame challenges along the way.

To learn more about our billing programs, contact Nancy Dolgin at NEMB at 508-297-2068 x232.

About NEMB

NEMB understands the importance of building meaningful relationships with entities and individuals within each municipality so we can ensure timely and compliant billing. Not only do we communicate regularly with fire and police departments, but we also take the time to get to know and network directly with town accountants, town managers, mayors, and others. We identify the key individuals within each municipality who can provide the critical information we need to bill ambulance services appropriately and as quickly as possible.

With nearly 10 years of experience in municipal ambulance billing, our credentialed staff members are trained in every aspect of effective municipal service billing. We specialize in auto accident claims that continue to challenge municipalities and result in significant revenue lost. We pursue auto accident claims as quickly as possible so our clients can take advantage of personal injury protection benefits before those benefits are depleted. Our expertise and focus on communication and relationship building help to maximize cash flow and ensure the fastest possible return on investment for the services provided. NEMB’s ambulance billing record has consistently yielded over a 90% collection rate.

Community paramedicine on the rise2019-01-02T17:52:51+00:00