Audit shows ambulance district is run efficiently
In June of 2018, the Ambulance District Board appeared in front of the Pendleton County Fiscal Court to ask for help in making their $50,000 bond payment for the new headquarters. A lengthy discussion led to several billing issues that were beyond the control of the district board.
The fiscal court approved the use of LGEA funds to cover the payment but also wanted to move forward on an audit of the district to see how the district is operating.
Charles M. O’Neal was contracted to perform the audit and at a special called caucus meeting on Friday, January 11, he presented his preliminary findings to Judge David Fields and Magistrates Alan Whaley and Rick Mineer.
“I am very confident that ambulance services are being ran very efficiently,” said O’Neal at the beginning of the presentation.
He went on to point out that any business or service could save on a rubber band or paper clip here and there, but there is no $100,000 in savings that he could find in the operating of the ambulance district.
He advised that the only way to affect the budget is to increase revenue or decrease expenses. As far as expenses, the only significant line item would be in the payroll line item which accounts for 75 percent of the budget.
“The payroll is middle-of-the-road. It’s about where you need to be and where you can try and stay,” he said.
He did suggest other options for the court to consider.
Presently, the ambulance district offers two Advanced Life Support ambulances. An ALS ambulance is provided when a patient is in more critical condition and a paramedic is required to assist in the treatment of the patient before and/or during transport to the emergency facility.
A Basic Life Support ambulance is an emergency transport provided by Emergency Medical Technicians, or EMT’s.
Presenting a timeline of when ambulance calls were made during a week, he identified peak times as well as times that activity was lower.
According to the information provided to the court, the peak times of ambulance calls were from 3 p.m. to 4 p.m. as well as 7 p.m to 8 p.m. Both time periods had over 100 calls during the week.
In contrast, the period of time from 1 a.m. to 7 a.m. saw an average of 36 calls per hour for the entire week. There is only a handful of calls made per hour during the overnight time period. Does that necessitate the cost of paying for a second ALS ambulance.
“Do you want to go down to one ALS ambulance,” asked O’Neal to the court.
As far as revenue, O’Neal pointed out that “It’s pretty slim on increasing revenue.”
Presently, there is a portion of each ambulance run that insurance, Medicaid, Medicare and other entities do not reimburse the district. The patient is responsible for payment of those fees. The district and the billing agency employs a soft billing that does not aggressively seek to recoup those costs.
An ALS run costs approximately $1,000, BLS run $800 and a non-transport run $200. According to O’Neal, Medicaid reimbursement is only $154 for ALS, $45 for BLS and $0 for non-transport. Medicare reimbursement is $475 for ALS run, $356 for BLS run and $0 for non-transport.
While the reimbursement is not close to covering a run, he emphasized repeatedly that proper paperwork on runs must occur so that billing and reimbursement is accurate.
Incorrect billing for Medicaid purposes could see an ALS run not documented correctly lead to a BLS reimbursement and a lost of $100. If that is done 5 times a month, you have lost $500 and $6,000 over a year’s time.
There are also a number of non-emergency runs that require transport but not truly a 911 emergency call. Residents have called for migraines, sprained toes and other non-emergency issues. Those calls cost the ambulance district but result in no reimbursement of costs.
There was much discussion among the court on what options they could pursue to handle these non-emergency transports that would not be as costly as an ambulance run while providing services to those who need it. The addition of after hour services provided by Harrison Memorial Hospital at the Family Care Associates office in Falmouth and the urgent care facility, MinuteMan Urgent Care, in the Mt. Auburn area located on AA is hoped to reduce the calls to 911 when medical services are offered in the evenings and on weekends.
The matter of bill collection was discussed on whether the district needs to change to “hard billing.”
Mineer asked whether hard billing would pay for itself.
O’Neal advised the court if a collection agency asked for payment up front, to thank them for their time and quickly walk away.
Instead, the only way a collection agency would get paid should be on a percentage of what they collect.
“Without a doubt the sooner an unpaid bill gets turned over to a collection agency, the better result in getting something. You need to develop a collection policy,” he said.
“We are sending out one bill, it’s getting ignored and no one is following up,” said Mineer.
That policy would include a formal charity policy for those that really need help.
He also pointed out that a “hard billing” policy would deter frequent fliers who are constantly calling for ambulance services.
He gave a scenario from the two counties he oversess, Barren and Metcalfe, of a female who called 911 services 62 times in one calendar year.
He pointed out that this time of usage for non-emergency reasons can be seen as Medicare or Medicaid fraud. He indicated he calls the state office on this fraud about six times per year.
O’Neal told the court as he summarized the preliminary audit, “I have thrown a number of balls in the air for you. Approach this with an open mind to make it the most cost efficent.”
“You have a good service and management team. I am very satisfied with the interaction of the management team and looking at the budget, I see no flaws,” he said.
Other discussion included two ambulance districts.
O’Neal indicated that Northern Pendleton Fire and Ambulance district operates a BLS ambulance and when paramedic services are needed they call on Pendleton County. There were 150 runs last year to Northern Pendleton with only $1,000 in reimbursement.
“Two ambulance licenses in a county this size is not cost efficient,” stated O’Neal. He added that trucks could be conveniently and strategically located throughout the county to provide services throughout the county with only the single license.
The situation with Kenton Ambulance closing their ambulance services was given significant coverage. They are collecting taxes from the northwest area of Pendleton County but have closed their ambulance services.
O’Neal indicated that he would provide Judge Fields with a contact in the state office to further discuss the options to Pendleton County on this issue.
“They cannot retain their ambulance license without providing services. They cannot collect taxes in that area,” said O’Neal.
Mineer asked if there is any group that purchases medicine together for reduced costs.
O’Neal said that there is not and added, “Darrin Brown is constantly looking online for the best prices for medicine.”
The same practice that O’Neal’s staff uses.
While lamenting that the $115,000 on building costs puts a stress on the budget, he did compliment on the forward thinking.
“The building is done for 18 more years. It was built for expansion and I applaud the vision to plan ahead,” said O’Neal while indicating the only future increased in costs would be if there is ever a need for three trucks.
“Ambulance services are pretty solid and in pretty good shape,” he concluded.
Judge Fields pointed out that “We wanted to make sure we are operating the best it could with no expectations that anyone was doing anything.”