How field documentation shapes EMS revenue — before billing ever gets involved

Elizabeth Gregerson: Hello, everyone. This is Elizabeth Gregerson with Becker’s Healthcare. Thank you for joining us for today’s webinar, “How Field Documentation Shapes EMS Revenue Before Billing Ever Gets Involved.”

Before we begin, a few quick housekeeping notes: we’ll start with a presentation and leave time at the end of the hour for Q&A. Submit questions any time using the Q&A box on your screen. Today’s session is being recorded and will be available afterward using the same link you used to join. If you have audio or video issues, try refreshing your browser, or submit a technical question in the same Q&A box.

I’m pleased to introduce today’s speakers: Steve Loures, President of the EMS Division at Coronis Health, and Haley Palmer, EMS Global Revenue Cycle Manager at Coronis Health. Thank you both for being here. Steve, I’ll turn the floor over to you.

Steve Loures: Thank you for that introduction. Hello, everyone, and welcome to the EMS revenue cycle webinar — we’re looking forward to it. Our goal is that you walk away with solid takeaways that help minimize your revenue loss and keep you compliant.

Before I get started, thank you to Becker’s — the go-to place for up-to-date healthcare information across all specialties, and I’m glad to be part of this.

A little about me: I’m president of the EMS division at Coronis Health. We’re a revenue cycle division that’s been around for quite some time — mostly large health systems, plus some government and other business. We have over 125 current customers.

Most of my adult life has been in the EMS world. I was the youngest paramedic in New Jersey at 20 years old — I used to joke I could defibrillate and intubate someone but couldn’t legally buy a beer. Today we’re a company of over 150 employees and seasoned executives, doing revenue cycle and compliance for the best of the best.

A little memory lane, since it’s relevant: my brothers and I started an ambulance service around 1990, in our parents’ driveway. Twelve years later we were the largest ambulance service in New Jersey — licensed across all five boroughs of New York, operating in Pennsylvania with six satellite offices, with our own fleet and training departments. A lot of people from that era still work with us today, and that’s what differentiates us from a pure revenue-cycle-only company. We later added air ambulance, general transport, 911, specialty care transport, and neonatal transport. We come from the industry.

That’s enough about me. I’d like to introduce Haley Palmer — an incredible executive who’s spent the last 12 years of her life in EMS revenue cycle. Between the two of us, we’ve made just about every mistake you could make, but our assembly line today is incredible. Haley, tell us about yourself.

Haley Palmer: Thanks, Steve. Good afternoon, everyone. I don’t love talking about myself, but as a quick overview: I’ve been in the ambulance billing industry for over 10 years. I work with a team of about 150 employees across multiple departments, focused on compliance and helping our clients achieve better financial results, while keeping up with compliance trends.

Steve Loures: Haley, that was a humble introduction. We have VPs of revenue cycle, directors, and COOs and CEOs of major hospitals calling us — not only for Haley’s expertise, but for our compliance work. We’ll get into that later. Many times there’s a compliance problem, and then they call the experts. We are the experts.

Steve Loures: Let’s get to the agenda. We’re going to talk about the history of revenue cycle — the “street to the spreadsheet,” a term we’ve used for years, because that’s a broken bridge, and there’s revenue seepage if you don’t have that street-to-spreadsheet process in getting the data right. It’s also setting the table for AI: these fundamentals have to be bulletproof before you can even talk about technology. We’ll cover what sets us apart, and then do some Q&A.

Steve Loures: Let’s get into the first part of the revenue cycle: pre-bill. There’s no registrar — people aren’t handing over an insurance card in an EMS environment — so we spend more time before adjudicating and billing a claim on pre-bill than most people realize. Haley, walk us through the details.

Haley Palmer: Absolutely. Our pre-bill team is the first line of defense in getting claims paid quickly. They verify patient demographics — name, date of birth, address — then look for insurance information. EMTs are focused on patient care, not paperwork detail, and demographic information often comes secondhand from family members or neighbors.

Simple example: my sister has been married for 10 years, and if you asked me her name today I’d probably still say her maiden name. That’s exactly what pre-billers catch — updating a name to the current legal one, not one from years ago. Same with “Mike” versus “Michael”: insurers need the full legal name. If there’s a hyphenated last name, we confirm whether the insurer wants the full hyphenated name or only half.

Dates of birth are just as tricky — easy to flip a month and day, or get the year wrong, and sometimes it’s missing entirely because it wasn’t top of mind in the field. Our pre-billers search databases to find it. Addresses are the same problem: did the patient move last year, three years ago? It’s a high-stress moment when an ambulance is called, so people forget or don’t provide their current address — and that’s what pre-billers dig into.

Once demographics are confirmed, we move to insurance. Sometimes EMTs get an insurance card, which is great — we verify it and move on. Most of the time they don’t have the opportunity, or the information is outdated, so pre-billers verify and update insurance IDs to get claims to the right payer without delay.

Steve Loures: Haley, great overview. Think about what’s happening in the field: paramedics and EMTs rushing through paperwork, sometimes in the back of a moving ambulance, transposing numbers and letters while caring for the patient — sometimes finishing paperwork in the ED when another call comes in. We know this because we’ve been in the business ourselves.

“Pre-billers” isn’t really the right name for the department — they’re really doing discovery. Every piece of information on the trip sheet, down to where the call happened, can matter. After being in this business for so long, we’ve made every mistake possible, and catching things upfront is where a lot gets fixed. Otherwise you get edits, you bill the wrong patient, you get HIPAA exposure, patients upset about a bill they shouldn’t have received. This isn’t a sales pitch, but this part of the business needs high-level management attention — it’s not casual. We’ll talk later about how we handle pre-bill discrepancies, but this only becomes more important as we keep patient data safe. Haley, thank you — let’s keep rolling.

Steve Loures: The next line of defense is our billers. Once pre-billers verify demographics, billers dig into the patient care report (PCR) to establish why the patient needed to go to the hospital, and why by ambulance. The first thing they look at is medical necessity. Medicare is strict here, especially for general transport — between facilities, or a discharge from hospital to residence. You need proof the patient required ambulance transport: three points of verification, covering things like bed confinement, severe hemorrhaging, unconsciousness or altered mental status, restraints, or immobility from broken bones.

For bed confinement specifically, you can’t just note “not ambulatory” — you need documentation of a complete inability to ambulate, or inability to sit in a wheelchair, and why (a broken hip, too weak to sit up). Without those points of verification, billing to Medicare opens you up to denials and audits. Every one of our Medicare general transport claims is internally audited before it’s ever billed — we have a dedicated department for it.

We’ve had customers hire us after a post-payment review on medical necessity to do the QA and compliance work. Revenue and compliance are almost the same word here. I’ve been through post-payment reviews myself: they find a few claims, then expand the review across your whole claim universe. If you’re not reading and justifying medical necessity — especially non-emergent calls, but really all calls — you’re exposed to a post-payment review. Audit types come and go, and there are a lot of audits happening right now; you see it in the news. I believe medical necessity is an area of compliance that doesn’t get enough attention — some organizations never really checked for it, or just had “a pattern of practice” of sending claims without QA, especially to Medicare, though now we’re seeing scrutiny from other payers too.

On top of the narrative, there are checkboxes, and if the checkboxes and narrative don’t agree with each other, that’s a problem too. We safeguard our customers’ charts with an additional QA step from people with real field experience who also know the law and have strong auditing skills — two people in our organization do only that. Thank you, Haley.

Haley Palmer: No problem. Continuing on that — those same checkboxes on the PCR matter for refusals of medical assistance too, where a patient decides not to be transported. As long as vitals were taken and the patient was checked out, that’s a billable charge, to insurance or to the patient if uninsured — Medicaid has actually built this into its fee schedule now. If we’re only glancing at the narrative, that’s money missed and left on the table for no reason. We cross-reference clinical details to confirm ambulance transport was warranted, with written proof for everything.

Same with what we call “pronouncements” — when a patient is deceased and EMTs are called to verify it. Without documentation of what was done, we could under-bill an ALS-1 or ALS-2 service. Under Medicare law, you’re paid a response fee even for a pronouncement, since you responded and were ready — some organizations don’t even bill that charge. And if paramedics were actively working up the patient before pronouncement, that can support a legitimate ALS-1 or ALS-2 charge that many organizations don’t fully recognize. Think about the cost: two paramedics, medication, response liability — every dollar counts, and we’ve found this to be a significant gap.

Continuing — differentiating levels of care (emergent, non-emergent, air ambulance and rotor-wing) matters a lot for billing. We’re not doctors and can’t diagnose a patient, but reading the PCR and EMT narrative gives us a clear picture of what happened and what we can bill. Insurers are getting pickier: they don’t like “pain” codes anymore. If the narrative just says “leg pain,” denial risk is high; but if EMTs document that it was an injury — a car accident, a fall — an injury code gets that claim paid faster. And the ALS-1 versus ALS-2 distinction is found in the narrative, and nowhere else.

Steve Loures: This isn’t just because I was a paramedic once—this is genuinely where revenue is lost. A single additional documented medication push can mean hundreds of dollars in reimbursement on one transport. Look at how many times medication is pushed: one extra documented push can shift a trip from ALS-1 to ALS-2, worth a few hundred dollars. We’re not pointing fingers at field providers — we know what they’re dealing with — but it’s our job to painstakingly review every trip sheet. We’ve found the disparity repeatedly: billed as ALS-1, when checkboxes actually supported ALS-2 criteria. That’s real dollars for our customers, and it’s also a compliance issue in both directions — you don’t want to upcode either. We’ve found this in every health system, hospital, and large city operation we’ve worked with.

Steve Loures: Haley, do you find a lot of ALS-2 confusion or discrepancies that we catch before a claim goes out?

Haley Palmer: Absolutely. We now train specifically on determining ALS-1 versus ALS-2 — it can be a gray area, especially around medication frequency, so all of our billers go through training to pinpoint the distinction, since it’s a real revenue gap that could otherwise be missed.

Steve Loures: This is another real place for revenue — along with the response fee for pronouncements — and it ends up right on the P&L statement.

Haley Palmer: With compliance, patient signature is required to bill a Medicare claim — and now Medicaid too, with pre-claim audits starting to require it. If there’s no signature, there needs to be a specific, valid reason — traumatic injury, paralysis, severe weakness — not a generic reason like “the patient was being treated at the time.” With Medicare, a claim without a signature will often still pay initially, but the real risk is the post-payment review: if they find a claim without a signature, that opens the door to a broader audit. The reason given also has to be consistent with the PCR — if the report says the patient was conscious and alert, but the stated reason for no signature is altered mental status, that’s not valid and the claim gets kicked back until there’s a valid reason, or the patient signs a form afterward.

This isn’t just a Medicare issue anymore — it’s across the board, and audits around signature are becoming more prevalent industry-wide. It’s almost its own QA category in EMS specifically, because the reason has to be valid and consistent with the narrative, and the audits are that detailed.

Steve Loures: That’s why we’ve built so much experience here — large revenue cycle departments often focus on bigger, higher-revenue departments, and EMS gets put to the side since it’s smaller. We’ve built an outstanding process around this specific topic because it’s a real liability.

I’ve been an OIG watcher for a long time — Office of Inspector General, compliance around contracting and kickbacks — and this is one of the areas I know well. We talked about medical necessity as the first-line Medicare/Medicaid audit target; now, for EMS, signature is right there with it. If the simple things from the field are done correctly, post-payment review becomes easy. It may sound like we’re belaboring the point, but focusing on this has genuinely helped a lot of customers.

This also means continuous feedback to the field — quality improvement information has to flow back to crews. We’ve found that, roughly, an 80/20 rule holds: about 20% of documentation from field crews needs correction. If EMS managers and directors know that, they can build their own QA process around it. I hope you’re doing the same in your operations.

Steve Loures: Haley, moving on from signatures — this is your area of expertise.

Haley Palmer: Yes, my favorite department. We call it AR follow-up, or collections — “correctors,” as we informally call them internally. This team handles appeals for standard denials (a claim marked non-covered when it was a 911 call, or marked as not meeting medical necessity when it clearly does), and also fixes anything missed upstream in pre-bill — a misspelled name, an outdated ID number — before sending it back out for payment.

This team also specializes by payer and by level of care. We have dedicated teams for air ambulance and rotor-wing trips specifically, since those claims are expensive and revenue is easily left on the table; they handle No Surprises Act (NSA) appeals, which matter a great deal since we can’t balance-bill patients for air ambulance and rotor-wing transport — if the payer is only making a small payment and we’re not contracted with them, we file the NSA appeal to recover an additional amount. We also have dedicated teams by payer — a full team just on Medicare, and one on Blue Cross, which is a huge payer with a lot of specific rules, especially around diagnosis codes. These teams spend the time learning the ins and outs of each payer’s requirements and keeping up with changes, and feed anything they learn back to the front end.

Our philosophy is “we train, we don’t complain.” It’s easy to point fingers at other departments, but we actively work against that. If collections finds something new — an uncovered diagnosis code, a policy update, a change in where claims need to be sent — that gets passed back to pre-bill and billing immediately, so we’re not repeatedly hitting the same denial. We fix it at the start rather than dealing with the same issue on every new claim, because collections deals with something new from the payers every single day.

Steve Loures: It’s definitely dynamic. If you have a subject-matter expert who knows Aetna inside and out, they catch a trend and it gets fixed quickly — not as one big lump of changes later. That’s why we like payer-specific and level-of-care-specific experts.

What sets us apart: we have rotor experts, Medicare experts, Medicaid experts, payer experts, and dedicated ALS-1/ALS-2 auditors — divide and conquer, an old term, but it’s true. We’ve made every mistake because we’ve been in this business for decades, and we’ve found this is the best way to minimize revenue loss, stay compliant, and catch a trend before it becomes a long-term problem. That’s why a lot of customers have stayed with us — some health systems we’ve billed and managed claims for over 15 years, through multiple changes in their own management. When you have 10- and 15-year relationships with dynamic health systems, that tells you something about the process. And we have educated executives who’ve grown up through this industry, which is really our number one asset.

Steve Loures: Everyone’s talking about technology, and we do too — I’m tech-forward, so is Haley, so is our whole management team. But people want to run before they walk. If the fundamentals aren’t done with purpose, no amount of technology magically fixes a claim, gets it collected, or corrects a mistake — all of that will go wrong without the basics in place. We’re looking forward to technology, but cautiously optimistic.

A couple of points: without a bulletproof assembly line, you’re not going to get efficient — that’s just a fact. Human expertise matters because our people have been through a lot in this industry; revenue cycle isn’t just revenue cycle expertise, you have to know the industry you’re billing for, and that’s where the best results come from. It sounds basic, but it’s often not the reality. We’re preparing for future integration, but we’re not assuming a bot or AI will fix our problems. We hope adjudication becomes smoother and more automated as things evolve, but “street to spreadsheet” really is the foundation of this business.

People like Haley Palmer, and other subject-matter experts across our specialty sub-teams, have made the difference — millions of dollars collected, and revenue that was previously lost or exposed to post-payment review, recovered. We run compliant and ethical, and I’m proud to be here on Becker’s helping others in EMS as the space expands.

Steve Loures: One more note before Q&A: EMS matters to health systems more than most people realize. I’ve also seen some hospitals starting their own ambulance operations — partly because there’s a revenue stream leaving the hospital otherwise, and partly because of the 911 and related opportunity around the hospital. Just a trend I wanted to flag.

Elizabeth Gregerson: Thank you so much, Steve and Haley, for a great discussion. We’ll begin the Q&A now — please keep submitting questions in the Q&A box. I’ll start with the first one.

Haley Palmer: The biggest thing with AI is making sure you have accurate information first. Our pre-bill process isn’t ready to hand off to AI unless EMTs are already getting close to 100% accurate information. Where we’re starting to slowly integrate AI is in the search for insurance information, since EMTs rarely capture it in the field — pre-billers verify demographics, and we’re beginning to use AI to search for and pull in insurance information to save time, with human review of what AI returns before it’s used. It’s the first step in that direction.

Steve Loures: We also use bots on accounts receivable — they sweep certain parameters, like AR over 90 days, by payer, and generate a report for someone to correct, since at that point it’s not collections anymore, it’s fixing claims that failed. I’d love to say AI is ready, but it isn’t — at least not for EMS specifically; I can’t speak to other specialties. It will be, eventually, but we’re cautious right now. Maybe our next webinar will be “AI, ready for EMS.”

Steve Loures: No — 100%. Under Medicare EMS guidelines, ambulance is treated as its own business. The signature isn’t just about billing; it also verifies that an actual patient was transported, which matters for fraud and abuse. If there’s no signature, EMTs have to document why, and that creates liability if that documentation isn’t accurate. Great question — I haven’t heard that one in a long time.

Haley Palmer: It does relate. The NSA appeal is the first step — you file the No Surprises Act appeal with the insurer or their broker first. If they decline to pay more, or the additional amount offered doesn’t meet requirements, that’s when the IDR process starts. Always attempt NSA resolution first; IDR is more involved, with its own fees and stricter requirements.

Haley Palmer: That depends on EMS and dispatch. For a scheduled transport, that information is often available in advance and can be entered into the PCR ahead of time. 911 calls are harder — dispatch and crews are focused on the emergent situation, so they’re not always capturing everything up front; it’s reliant on what information reaches dispatch and gets passed to the EMTs.

Steve Loures: Rarely — a scheduled transport can never be billed as emergent. If it’s ER to ER and the patient needs a higher level of care that the sending facility can’t provide, it can be billed as emergent depending on documentation — but there’s a high audit rate on facility-to-facility emergent claims. One thing I’ll add: we also have former payer employees on our team who help us understand payer edit logic from the inside.

Steve Loures: Haley, can you speak to the general transport side specifically?

Haley Palmer: General transport actually needs more documentation than emergent transport. Insurers assume, most of the time, that a patient could have taken a taxi or rideshare — we have to prove that’s not true, that ambulance transport was necessary. The physician certification is the documentation of why the patient can’t be treated at the current facility and has to be transported to the next one; it has to be signed and fully filled out with the medical necessity reasoning.

Steve Loures: It’s interesting that physician certification is required for audits, but on its own doesn’t establish medical necessity.

Haley Palmer: Right — it can actually work against you if the physician’s documentation and the EMT’s documentation don’t match.

Steve Loures: These were “pencil-whipped” for years — a big audit issue historically, especially for general transport and dialysis patients. Scrutiny on general transport is higher than on a 911 dispatch, since a 911 call defaults to the “prudent layperson” standard, whereas a hospital discharge might reasonably go by wheelchair van with an attendant instead. That’s why documentation matters so much here.

Haley Palmer: Our process matters even more for smaller agencies — catching everything possible on the front end gets a clean claim out quickly, and that money comes back faster, which these agencies rely on heavily.

Steve Loures: Rural agencies face real financial pressure, and I think there’s an opportunity for ambulance service expansion in rural areas. Rural Medicare fee rates are also higher, which helps.

(Noted with about 10 minutes and five more questions queued.)

Haley Palmer: That relies heavily on the narrative. Without narrative context for why 911 was called, you’d likely use an unspecified code — pain unspecified, or illness unspecified. Vitals themselves (elevated heart rate, high blood pressure) can also support the code chosen.

Steve Loures: That’s a tough one — Medicaid dollars flow through the states, so relief varies a lot by state. I’m not certain which state this question is coming from, but we have a government-relations resource who’s more in tune with this and could follow up directly.

Haley Palmer: Most time goes into verifying demographic and insurance accuracy across payers — that’s the biggest point, since pre-bill is our first line of defense. Two of our main tools: Availity, for payer verification (anyone with medical billing experience knows Availity isn’t always the easiest system to work with), and a Social Security verification tool called One Source, or Passport, for finding Social Security numbers.

Steve Loures: And when there’s any doubt — for example, Blue Cross alone has 14 different places a claim might need to go — we’ll actually make a phone call to verify, rather than risk it going to the wrong place the first time.

Haley Palmer: We do — our billing system checks for outright errors before submission: missing ID numbers, missing place-of-service information, and similar issues we’ve configured it to flag. Billers run an error report every day after billing and fix anything flagged. It’s been a great tool for us.

Haley Palmer: Anything not time-sensitive is non-emergent. Emergent is essentially a 911 call — the one exception being ER-to-ER transport that’s time-sensitive because a higher level of care is needed, and that need has to be documented.

Steve Loures: That ICU example sounds like it could be a Specialty Care Transport (SCT) — we haven’t talked much about that specialty. If it meets SCT criteria, it can be billed at a higher rate given the complexity, separate from the emergent/non-emergent question. Worth checking the specific SCT criteria for that case.

Haley Palmer: Right — SCTs are technically billed as non-emergent, but at a higher rate, since there’s often a nurse or physician on board and the documentation reflects that complexity.

Haley Palmer: Lack of detail is where crews miss out — not documenting every procedure and medication given (CPR, additional interventions) beyond a routine “vitals taken, transported” note. That’s where EMTs sometimes fail to note that they did something extra, and that’s where the revenue gets lost. Poor handwriting and narratives that don’t match the checkboxes are common contributors too — if the checkboxes say one thing and the narrative isn’t clear enough to support it, we can’t justify the higher level, and we downgrade the claim. In those cases, we go back to the EMS director for clarifying documentation. We’ve recovered real revenue — hundreds of dollars per case in some instances — just by cleaning up narrative quality. It sounds like a broad answer, but that’s genuinely what it comes down to most of the time.

Elizabeth Gregerson: Thank you both — that’s all the time we have today. Thank you again, Steve and Haley, for an excellent presentation. Before we go, thank you to Eliza Almeida for organizing this, and to Casey Covello and the Becker’s team, and to Coronis Health for sponsoring today’s webinar. Thank you all for joining, and we hope you have a wonderful rest of your day.