City of Fredericksburg
Fire, Rescue and Emergency Management

Revenue Recovery Program:      
“Frequently Asked Questions” 

Why is the City of Fredericksburg implementing this program?
Revenue recovery is the process of obtaining financial reimbursement for the cost of providing medically necessary ambulance transportation. Medicaid, Medicare, and most other private insurance policies (health, auto, and/or homeowners) already allow for reimbursement for this service. Fredericksburg is implementing this program to seek reimbursement of these funds that will be reinvested in our Emergency Medical System to address the growing needs of our combined system.

Why are EMS agencies in Virginia considering billing for services?
Over the years EMS agencies have suffered a decreased level of federal, state and local funding. Concurrently there has been a rise in the cost of EMS expenses – operational, training, medical supplies, etc. There has been a widening gap between the funds that are provided by the government agencies, those that are collected from fund raising efforts and the costs to keep EMS agencies functioning efficiently and as expected by the public they serve. Billing for services can serve as a tool for increasing the budget of an agency, which can then improve the standard of care provided to the patient by purchasing much needed equipment and paying for much needed training of personnel, among other things.  In addition to the increasing problem with funding, the call volumes of EMS agencies everywhere is rising; in many places the increased call volume is overwhelming the system such that the result is in the implementation of career personnel…at an additional cost. Many places where volunteerism has suffered the most, career staff have been added to continue to provide the same services offered by the agency and expected by the public. In order to fund the much-needed new additions and changes to the system, billing for services has been implemented.

What are the charges for emergency medical transport services?
Charges include: $350 for BLS, $450 for ALS-1, $550 for ALS-2, and a mileage fee of $9 per mile.

What happens if I do not have insurance or cannot afford to pay for this service?
City residents who do not have any insurance and qualify for compassionate billing can submit a waiver, and fees will be waived. Other county residents can also apply for a waiver to determine if they qualify.

What if my insurance company will not cover my ambulance transport bill?
In accordance with the Compassionate Billing Policy, the City's billing service will attempt to gain all information required to show the medical necessity of the transport. However, if the claim is ultimately rejected, the department will consider the charge uncollectible for City residents.

If a resident has reached an insurance limit (ambulance service) for the year and additional services are required, will the citizen get a bill for these additional services, or can the fee be waived?
Several billing vendors advised that this should not occur, as most if not all policies do not have a limit on emergency transports related to EMS service. If this did occur, the locality could decide to waive some or all of the charge for residents based upon the circumstances. Under Fredericksburg's Compassionate Billing Policy, additional fees would be waived.

How does the billing process work?
The City will contract this service out to a private company to handle the process. After patient care is provided, insurance information will be obtained routinely, often at the hospital. The City will waive co-payments and deductibles for city residents. Non-insured residents will receive an initial statement from the billing company, while insured residents will receive an explanation of benefits (EOB) from their insurance company. Non-insured residents may apply for the hardship waiver.

How much money should be realistically expected through billing for services?
This varies from agency to agency, region to region and is difficult to compare because of the number of factors that are involved, including (but not limited to) demographics, location, percentage of insured patients, number of calls per day/month/year, type of billing level, individual-agency set fees for services, etc. Major factors that can influence the amount, or percentage, or funds that are received include the demographics, estimated number of calls, level of services provided and level of billing.

Can volunteer agencies bill for services?
Yes, and many volunteer agencies currently do bill for services. There is a misconception among some that if billing for services is implemented, it requires that paid staff be hired and incorporated into the system. While some volunteer agencies have chosen to utilize funds received by billing for services to hire and maintain a career staff, it is not required or expected. How to manage the personnel is an agency-to-agency decision; those with a plethora of volunteer staff may not need to consider adding paid personnel. How to manage the funds received through billing for services is also an agency-to-agency decision, and there is are no state laws decreeing what a volunteer agency may due with funds collected by billing for services.

How much money can you realistically expect to make through billing for service?
This amount received through billing for services varies for each individual agency, area & region.  The amount of money earned for the agency through billing for services depends on several important factors, such as demographics of the population (population number, percent insured, etc) and what billing strategy an agency chooses to follow (soft or firm). For help determining a cost benefit ratio, or how much an agency can realistically expect to receive, there are many good resources available. It is recommended that an agency get in touch with other agencies of similar size and patient demographics to determine the risk, benefits and anticipated costs of billing for services.  Another resource for determining a realistic net income number is a billing company; at present there are no agencies in Virginia who are providing the patient care and billing services. All Virginia EMS agencies billing for services have out-sourced the billing to a billing service or company due to the significant workload, making the currently used billing companies an excellent resource to determine a realistic net income number.

What can the money received from billing for services be used for?
The money received by an agency for billing for services will go to serve the agency as determined by those in charge of finances. It may be a combined effort with local government, or a decision made only by the staff/members of that particular EMS agency. Often the funds go to help purchase equipment, including ambulances, or supplies. Some funds are used for training purposes and are designated to help further the education of the personnel. Other agencies will use the funds to pay salaries and benefits for career staff to provide the treatment & transport services.

Will I have to pay for services if the ambulance does not transport me?
If you or family members are not transported, there will be no bill for services rendered. Revenue recovery is based on what is termed "loaded service," whereby someone is actually transported.

Will billing impact the donations and fund drives for volunteer EMS agencies?
It is commonly heard that an agency that begins billing for services will see a significant decrease in the amount of funds collected by annual fund drives and donations to the agency. Most agencies and billing companies alike who have researched the statement have found any evidence to back up the claim. It has been found that billing for services has a minimal impact on annual fund drive and donation collections.  As a part of public education, the public should be informed of what, if any, changes are being made to the agency once billing for services has commenced. Included with the mailer for annual fund drives should be a noticed explaining that although the agency is billing for services, and that such bills are being sent to insurance companies. It should be explained the purpose of billing for services is to serve as an adjunct to donations, which provide the funding necessary for maintenance of daily operations.

How can revenue recovery benefit the community delivery of EMS care?
The benefits to revenue recovery are vast. Briefly, some of the most commonly mentioned benefits to the community are: increased availability of personnel, increased education level (advanced life support, specific medical training such as ACLS, PALS, etc), improved equipment allowing a provider to better care for their patient, improved response times due to increases in staffing and/or additional units/stations, and improved QA/QI systems.  The concerns of revenue recovery are real, but in many cases are outweighed by the many benefits. By implementing revenue recovery, an agency can increase the number of higher-trained personnel, thereby increasing the standard of care available for the patients. An increase in the amount of funds available for career personnel allows an agency to increase their staffing levels, thereby increasing the number of ambulances available to serve the community. An increase of available staffed ambulances results in a decrease of delays in getting to a call; if an agency routinely receives two to three calls at a time but only has two staffed ambulances, the third call is delayed until one unit clears from the previous call or another EMS agency comes from further out to answer the call. The increased availability of a staffed ambulance in the response area improves response time and better serves the community. Improved equipment can allow improved patient care, whether it is a new ambulance with improved safety features and better lighting for patient exams or a new cardiac monitor with the ability to monitor vital signs as well as the heart rhythm. The new equipment can improve patient comfort and care, benefiting the community by increasing the standard of care available.

Will visitors and non-City residents be charged a co-payment?
Yes, only City residents will have their co-payments and deductibles waived.  

How does revenue recovery work?
The patient’s insurance (Medicare, Medicaid or otherwise) will be billed first for the full service fee based on the level of care provided. There are four basic rates: ALS Transport Level 1, ALS Transport Level 2, BLS Transport and “Loaded” Mileage. 

What is billing for service?
Billing for service is the mechanism by which many EMS agencies are pursuing revenue recovery.  When a patient is treated and transported, the insurance companies, and then the patient, are billed for the services performed by the agency providers. There are funds created in every insurance policy, including Medicare, Medicaid and private companies, to reimburse for those services rendered by pre-hospital care personnel; those funds are left untapped by agencies not billing for services.  

What is revenue recovery?
Revenue recovery is the collection of fees for the treatment and transport of patients to the emergency department (or other hospital ward) by an EMS agency licensed to treat and transport patients. In most cases, the agencies considering revenue recovery are those involved in emergency 9-1-1 transport of patients from locations outside of the hospital. These agencies might be volunteer, career or a combination of both. Overall, research has shown that more than 90% of the fees collected will be paid by Medicare, Medicaid, insurance companies or a subscription program. That number will vary from region to region and based on the demographics of a population.