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HomeMy WebLinkAboutAgenda - 08-18-2009eAG ed cdtgl09 ORANGE COUNTY BOARD OF COMMISSIONERS ACTION AGENDA ITEM ABSTRACT Meeting Date: August 18, 2009 Action Agen a Item No. SUBJECT: Approval of Proposed Emergency Medical Charge Review Process DEPARTMENT: Emergency Services, Revenue PUBLIC HEARING: (Y /N) No ATTACHMENT(S): Proposed Emergency Medical Charge Review Process INFORMATION CONTACT: Frank Montes de Oca, 245 -6100 Kim Woodward, 245 -6100 Jo Roberson, 245 -2727 PURPOSE: To present for adoption proposed appeals process for a concerned citizen to dispute a charge for emergency medical services rendered. BACKGROUND: From time to time since Orange County began charging for Emergency Services in November 1996 instances have occurred when medical charges are questioned due to billing errors, patient care complaints, and mistaken identity. These concerns are addressed quickly by staff and are typically resolved. Infrequently, there are cases where careful review by staff leads to the recommendation that the charge for emergency medical services rendered to the patient be voided. Since 2000 there have been only four reviews that resulted in bills being waived. In 2008 several transports occurred causing the Revenue Department Director and Emergency Services Department Director to review them for correctness and appropriateness. This was an anomaly and the procedure causing these billings has been corrected. Currently only the Board has the authority to abolish emergency medical charges. However, it would be a breach of patient confidentiality under Health Insurance Portability and Accountability Act ( HIPAA) if the emergency medical documentation required for a determination were to be presented in a public meeting for Board action. HIPAA and state laws do not necessarily preclude sharing of patient information among and between EMS providers and other health care providers, law enforcement, regional and state quality assurance systems, and other users of public health data. However, in the exchange of such information, EMS providers and systems are to be vigilant in ensuring the protection of data for the purpose it is being released. The sharing of protected information should be kept at a minimum ensuring that anyone with access has received the training required to access private health information. Staff in consultation with County Attorney's Office has developed an appeals proposal that would provide for timely, objective review and resolution of patient concerns by the appropriate County officials in compliance with HIPAA regulations. 2 Under the proposed process, the County Manager, or designee, would be delegated authority by the Board to receive the review and recommendation of the Emergency Services Director and /or Revenue Director, and make a final decision on whether a bill for emergency medical services should be voided. The specifics of the proposal are contained in the attachment. If approved by the Board, Staff will begin immediate implementation of the process. FINANCIAL IMPACT: Management decisions, under authority delegated by the Board, to void patient bills would impact total revenues received for by the County for Emergency Medical Services rendered. However, Departmental experience indicates only a small number of cases have occurred in the past decade that would have amounted to less than $5,000. RECOMMENDATION(S): The Interim Manager recommends the Board approve the proposed Emergency Medical Charge Review Process. 3 ORANGE COUNTY BOARD OF COUNTY COMMISSIONERS Hillsborough, North Carolina Emergency Medical Charge Review Process PROPOSED OBJECTIVE: When complaints or concerns arise after EMS care has been rendered and billing conducted, customers should have an appropriate venue for a fair and timely review of charges and records. The review process must be sanctioned and delegated by the Board of County Commissioners since theirs is the only authority to void medical fees, should that be the ultimate outcome, Also, the Health Insurance Portability and Accountability Act (HIPPA), the federal regulation that regulates protected health information, dictates that patient medical records must be handled and reviewed by persons trained in the protection of health information. This document outlines a proposed process for the proper review of medical records and the resolution of a concern on behalf of the Board consistent with protected health information rules. SCOPE: This review process applies to billing for Emergency Medical Services rendered to patients. Emergency Services charges to special events standbys are not included. POLICY /PROCEDURE: Questions related to billing for EMS services rendered typically fall into one of two categories: Billing, filing and insurance concerns, (i.e. a patient's insurance company does not have enough information to process the claim) or medical care complaints (i.e. the patient is concerned the Emergency Services unit failed to provide the appropriate level of service) However some complaints will require investigation in both categories. Billing, Filing, and Insurance Concerns • All concerns about billing, filing, and insurance should be directed to the Revenue Department. 4 • If the EMS division receives a complaint and determines that the issue is predominately one that involves billing, filing, or insurance the complaint information will be forwarded to the Revenue Department. Medical Care Complaints • All concerns about medical care rendered by the Orange County EMS should be directed to the Emergency Services Department. o The EMS Operations Manager will acquire the patient care report. o The EMS Operations Manager, in compliance with federal, state, and local confidentiality rules will contact the complainant and will ascertain their relationship to the patient. o The EMS Operations Manager will document the call and will log the question on the appropriate form. • If the Revenue Department receives a complaint and determines that the issue is predominately one about medical care rendered by Orange County EMS, the complaint information will be forwarded to the Emergency Services Department. • If the complainant is not lawfully allowed to represent the patient, the complainant will be informed that Emergency Services is unable to discuss the details of the medical care. Emergency Services will describe who is legally able to represent the patient. • If the complainant is lawfully allowed to represent the patient, the EMS Operations Manager will make reasonable effort to discuss the concern with the patient or their representative. • If after speaking with the EMS Operations Manager the patient or representative requests further review related to the care rendered, the EMS Operations Manager will forward the concern to the Emergency Services Director. o The EMS Operations Manager will provide to the ES director a synopsis of the concern as it relates to the medical care rendered, the contact information for the representative, and any appropriate documentation. 2 5 o The Emergency Services Director will review the documentation and may contact the patient or their representative. The Director may also confer with the Medical Director as necessary. o The Emergency Services Director will submit a written recommendation on whether the bill should be voided to the County Manager, or County Manager designee, for a final decision. o The complainant will be notified in writing of the County Manager's decision. The Revenue Director will also receive a copy of the notification. • If the patient or representative has further questions or concerns related to billing, filing, or insurance the issue will be referred to the Revenue Director. o The Revenue Director will continue the complaint documentation per the guidance above. C