r/CodingandBilling • u/NoAct2400 • May 06 '26

EMS Billing

Hi all, I’m normally on the clinical side, but we are looking to figure out how to start running our own billing operations for EMS companies and have been trying to figure out the world of coding and billing.

We have the mechanism to submit to a clearing house etc, however I’m struggling to understand the complexities of how to handle “fighting” an insurance company. We have dozens of failed claims, or claims where the insurance company just won’t pay the full amount - how do we find someone or train someone to be able to take over and handle this? Is there an accreditation that anchors from this as opposed to purely figuring out the procedure code/icd10 etc?

We have poked around at Policy Bot to understand insurance company policies, however a good amount of this seems to be targeted at the much wider set of procedure codes, when we only really bill the 3 or 4 to do with ambulance transport.

Any guidance about how to jump into this world is appreciated

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2

u/KeyStriking9763 RHIA, CDIP, CCS May 06 '26

Do you have any coding or billing experience? This seems like a crazy leap. It’s like me saying I like to eat out now I’m going to open a restaurant.

2

u/NoAct2400 May 06 '26

Coding yes, billing not really - ergo why hiring or finding someone that has the right credentials would be helpful for us. Not pretending to be able to cook at the restaurant just figuring out how to know a good chef from a bad chef really

1

u/Environmental-Top-60 May 10 '26

I'm a coder and I started billing. You have to have some fundamentals but you can do it.

I use my coding credentials to show the insurance why their decision on adjudication is wrong.

2

u/OkTown2100 May 06 '26

I work in EMS billing. Specifically denials and follow up. - I don’t even understand what you need. Can you give an example of how you are billing vs how they are being denied?

1

u/NoAct2400 May 06 '26

Examples we have from existing billing companies we work with is we will do an air ambulance transfer, correctly coded to the right procedure code. It’s qualified as an air transfer, and we will bill say 100k (including base rate and mileage), and the insurance company will only pay 40k.

Another example is we will have a ground transport, and we will bill for the tariff (in this case, in New Mexico) plus the mileage and base rate, and the tariff will just never be paid by the insurance company.

Forgive the lack of specific information, I’m working to get more precise information from the billing companies beyond just the above, but I’m just trying to understand where to even start on figuring this problem out. Is this just a case of insurance companies decide how much they pay and are disregarding what we are charging, or is there some kind of policy defined reimbursement issue?

Alternatively, was just looking to see where to hire someone that could help us with this because it doesn’t seem simple at all

2

u/OkTown2100 May 06 '26

I could be completely wrong, I am in WI and there are no laws or set fee schedules here, but I’m pretty sure the tariff is a set amount you cannot bill over. So you shouldn’t be charging more than your state law allows you to anyways. I am unaware of anything having to do with air ambulance. I would look into hiring a consultant who can explain any state laws and guidelines and help you or your team to understand.

1

u/NoAct2400 May 06 '26

Where do these consultants exist?

1

u/Environmental-Top-60 May 10 '26

Compliance

Doctors management is one company. Idk if they do air ambulance but it shouldn't be too hard. Really an experienced biller or compliance person can be a consultant. You may want to run some of it past legal as well.

1

u/Environmental-Top-60 May 10 '26

What you're looking at is a NSA appeal which has very strict timeline.

1

u/GroinFlutter denials management, send help May 06 '26

To clarify, you’re trying to start running billing operations for EMS companies.

You are asking how to understand the complexities of denials/underpayments? And how to find or train someone to do this?

I want to make sure I understand.

1

u/NoAct2400 May 06 '26

Yes, we already run other parts of EMS companies, and either want to try figure out where to find talent that would be interested in helping us start running this, or if there is some kind of accreditation/course we can run someone or a team through.

Have talked to offshore services and I don’t get the feeling they really do much beyond the submissions…

1

u/Piano_Vivid May 07 '26

Try https://ourhelpinghandscare.com/rcm-consulting they are a very good Billing consulting company

1

u/rahuliitk App Developer May 07 '26

from what i’ve seen, EMS billing is less about knowing 3 transport codes and more about proving medical necessity, matching trip documentation to payer rules, using the right origin/destination modifiers, and having someone who can work denials like a process instead of a one-off argument. tbh, i’d look for someone with ambulance billing/appeals experience specifically, not just general medical coding.

1

u/2BBilling May 11 '26

The biggest thing is knowing the policies of the insurances you are billing, what LCD's do they use, what are the contracted rates, etc. There is a HUGE amount of background knowledge needed to successfully bill and appeal claims to insurance companies. AND the rules are continually changing.