Breaking down EMS Reimbursement

EMS is an incredibly new and volatile field. Having just started in the 1960s, EMS has had very little time to develop in comparison to nursing, doctors, and other medical professionals. As a result, the basic infrastructure of a healthy profession such as unionization, long-established educational tracks and degrees, and insurance support does not exist in the same way that others professions have it. This article will evaluate the current state of EMS funding, provider pay, and the reasons behind why EMS reimbursement rates remain low to this day - and what can be done to fix it.

Insurance Billing Systems

This is perhaps the largest reason why wages remain low for EMS providers. When nurses, doctors, or other allied health care providers in the hospital provide a service or perform an intervention, it is billed individually. Each service generates an entry in the patient’s record that will later allow for billing. This is called itemized billing. For instance, an RN that provides 2 medications and then woundcare has generated three billable items. Each intervention has a set amount that the patient can ultimately be billed for. Over the course of a hospital stay, this can add up significantly. As of 2022, the average hospital stay over the course of 3 days will cost up to 30 thousand dollars (Healthcare.gov, n.d.). With every day and every intervention or medication provided, healthcare organizations are able to bill for more.

EMS, on the other hand, is currently only able to bill per transport. If a patient is not transported, then no bill can be generated. A common example of these calls include hypoglycemia patients, in which providers provide glucose on-scene, return the comatose patient to a fully alert and oriented state, and depart the scene without further need for transport as long as the patient can maintain their own blood sugar levels. Rather than being able to perform itemized billing for each medication, assessment, or intervention provided to the patient, EMS providers are provided funding based on a flat rate fee schedule controlled by Medicare/Medicaid.

Medicare/Medicaid billing consists of 4 core items: a flat rate for transport, a modifier based on the capability of the transport unit (ALS vs BLS), a geographic location modifier (to provide rural services more funding for longer transports), and a per-mile fee. With over 72 million patients enrolled in Medicare/Medicaid nationwide and government reimbursement making up the single largest payee for healthcare, Medicare/Medicaid sets the standard to which insurance billing in general is done in the EMS industry (Commonwealth Fund, 2019).

Image sourced from CMS.gov

The above image shows the modifiers for each level of service. Medicare/Medicaid uses a set of algorithmic criteria to decide what level of service something will be billed as to adjust billing.

For example, a standard BLS bill for transport through a 911 service may bill 300 dollars as the initial cost for transport. With BLS-only ambulances having a modifier level of 1.00, no modification will be made to the bill based on the level of service. The patient is transported a total of 10 miles. If the ambulance service was able to bill at 10 dollars per mile (example only), then the patient will have a total bill of roughly 400 dollars USD.

In that time, the 911 service had to dedicate a unit out of service to transport the patient, use supplies to provide care, provide a comprehensive assessment to the patient, and pay staff. In addition, the ambulance crew will provide a patient care report that will be added to the patient’s hospital file and allow for continuing the care.

In another example, an ALS unit consisting of a Paramedic and an EMT are dispatched to a high acuity call. Once there, they have to do serious and invasive interventions in order to stabilize the patient on-scene and save their life. The patient as a high priority patient to a local hospital. Because of the severity of the patient’s condition, the patient is classed as an “ALS2” patient and receives a higher modifier for transport.

With the base rate being 300, the ALS2 modifier being 2.75, and the mileage being 10 miles (at a rate of 10 dollars per mile), the total bill would be roughly 925 dollars. During this call, the patient was provided a multi-agency response consisting of 2 ambulances and 4 providers with an extensive amount of equipment used. This bill alone may not be enough to cover costs for the equipment provided.

Equipment used during emergency calls can quickly shoot costs up. For instance, an Ez-IO needle set (often used for obtaining vascular access in a patient that is high priority and a simple IV will not work) can cost up to roughly 450 dollars. A rescue medication for diabetic patients such as Glucagon can cost up to 250 dollars per dose. These two devices/medications may be used together on a high-priority hypoglycemic patient, bringing the cost up in major supplies alone up to roughly 700 dollars. If the cost for transport, providers, and opportunity cost by taking extra units out of service to respond to the call is added in, the call total is easily above 1000 dollars in expenses - for which the EMS service will receive only 975 dollars for.

For perspective, the average medium-acuity emergency room visit prior to insurance in New Mexico cost approximately 1,574 dollars (Learish, 2020). In the CBS News list referenced, New Mexico is a moderately costly state and ranks 30/50 for most expensive average ER visits. The scenario described above would be a higher acuity, and still receives significantly less than the hospital will for their own itemized billing.

EMS may have begun as a transport-based industry, but modern EMS providers are much more than merely stabilizers on the way to transport. With community paramedicine programs being developed, agencies providing care approaching ICU levels in the field, and scopes of practice advancing nationwide, it is important for insurance agencies to recognize that itemized billing needs to apply to EMS services, too. EMS is not just a ride to the hospital - it is a multi-faceted healthcare industry that intersects with public safety and brings emergency care to the patient.

EMS billing systems and the federal government need to adapt to allow for funding parity between EMS systems and hospitals. While EMS does an inherently different job, stabilizing and emergent medical care remains the same regardless of where it is delivered. With EMS providing care in an inherently imperfect environment, it is important to allow for adequate reimbursement and funding to allow EMS providers to continue to do their job and serve their communities.

Works Cited

Commonwealth Fund. (2019, December 13). What Is Medicaid’s Value? https://www.commonwealthfund.org/publications/explainer/2019/dec/medicaids-value

Healthcare.gov. (n.d.). Health coverage protects you from high medical costs. https://www.healthcare.gov/why-coverage-is-important/protection-from-high-medical-costs/

Jansen, C. E. S. (2020, December 8). EMT pay, do you understand the reasons that it’s so low? Distance CME. https://www.distancecme.com/understand-reasons-low-emt-pay/

Learish, J. (2020, December 4). The most expensive states for ER visits, ranked. CBS News. https://www.cbsnews.com/pictures/emergency-room-visit-cost-most-expensive-states/46/

Rescue Essentials. (n.d.). SAM IO Needles. https://www.rescue-essentials.com/sam-io-needles/