The elected officials are casting their votes regarding a resolution that has been discussed, debated and discounted many times over the last year. One reason has echoed for why this resolution must be approved: economics.

The vote has unanimous approval, and the fire chief is given the responsibility to successfully implement patient billing for all fire department ems calls. While reviewing his copy of the resolution, the chief concludes that he hasn't been given a complete copy of the document, as it contains no information regarding a few basic questions, such as:

* Who will perform the administrative tasks?

* What legalities exist?

* Where can instructions be found, and where do we begin?

* How much education and knowledge is necessary to perform such a task?

Each question gives rise to other questions, and soon it appears as though the task before the chief has the same exponential degree of difficulty as the exponential number of questions. The chief remembers seeing an advertisement that may provide a solution. The ad was for a company devoted entirely to patient billing for ambulance services, and he soon learns that several companies offer such services. Would an outside service be able to provide a cure, he wonders.

The hypothetical situation described above isn't that uncommon today. Many fire-based ems systems have already faced this situation, and many others are beginning to face it. Other ems systems are dealing with the same circumstances.

Many departments facing this situation are wondering whether patient billing services should be conducted internally or if this task should be outsourced. The answer depends on the organization. What fits one ems agency doesn't always fit another. Therefore, the fire chief/administrator will be required to do some research and analysis. At the very least, this article can help fire service managers make the best decision.

Those interviewed agreed that billing for ambulance services is costly, time-consuming and forever complicated by the constantly changing requirements imposed by Medicare. Many ems services simply don't have the resources for it.

Bill Metcalf, division chief for North Lake Tahoe Fire Protection District, Tahoe City, Calif., said that their decision to outsource wasn't because of software or related problems, but because of a combination of factors, including:

* Increasing complexity of billing processes, procedures and paperwork.

* Constantly increasing clerical workload, despite static call volume.

* Concerns about increasing liability, as former "errors" are now considered fraud.

* General track record that professional billing services generate more revenue than in-house, part-time systems.

Metcalf added, "Increasing the workload for our departments would have required us to increase our staff under our old system. With outsourcing, we'll free up a significant block of administrative support hours, thereby eliminating or delaying the need to add staff."

Some ems providers opt to take on the challenge of internal patient billing for ambulance services. These agencies have expressed that their decision to keep the billing in-house provides them the luxury of retaining control, though this control comes with its own costs.

Most pointed out that the decision to keep procedures in-house required them to hire individuals with the experience and expertise to perform the billing of ambulance services in today's world. This meant that the administrators of these services had to do enough research to understand what fundamental knowledge was required for this activity before a job description could be written and interviews conducted.

Setting the salary also required research by management. These personnel play a visible role in the organization and should be compensated accordingly. They're required to have face-to-face contact with patients, and they also must maintain contact with insurance companies and Medicare and Medicaid providers. Therefore, public relations is an important function of their job.

Before an organization can make an educated decision as to whether patient billing for ambulance services should be provided in-house or outsourced, several questions should be considered.

Wallace Stovall, a retired city manager, relayed those concerns best in the following questions.

* After all the expense for software, hardware, training and commitment of personnel, what if we couldn't do it right?

* If we had to abandon the project, how would we justify the loss?

* Who would be responsible for failure? The fire chief, city manager or both?

* If we have a change in personnel, management or city council, will the project succeed?

* Will the city governing board stay with the project long enough to debug the system and give it a fair trial?

* Do the fire chief, city manager and/or mayor want their reputation endangered by an unproven project with the potential for very bad publicity?

* Does our current billing comply with the necessary requirements?

* If not, what improvements and/or additions, such as equipment and personnel, would be necessary? How much would these additions cost?

* Do we have clear and identifiable alternatives, and what are the reasons for them?

* How will this decision affect customer service?

* Does my city want to deal with patients, Medicare, Medicaid and insurance?

* How will your software provider treat you after the purchase?

* Will the city have a backup source for problems with software, procedures, client services, the law, etc.?

* If a decision were made to have these services provided by an outside specialist, would individuals from our community volunteer to serve as members of a task force designed to identify critical issues and performance parameters required for the delivery of this process?

* How detailed and in-depth will the information in your request for proposal be? (Although billing services are considered professional services, most of which don't have to go out for the rfp, it's in your best interest to do so, just in case of problems.)

* What additional services could an outside vendor provide that might prove necessary in the future, such as documentation, training, financial reports or consultation?

* Is your billing service a collection agency? How many government-based services are they employed by? Check all their references.

Stovall added, "Both the city manager and fire chief have a constant need to protect their positions. When projects of such magnitude and expense as these fail, then justification becomes impossible, and future ventures become doomed from the start. The seniors in any community have a strong lobby, and they don't forget and forgive easily."

The bottom line as to the success or failure of any patient billing system depends on the dedication of everyone.

No outside source providing patient billing for ambulance services can guarantee an increase in revenue collected. As a service provider to ems systems across the nation, we have dramatically increased revenue of most services, but this isn't always the case.

For example, Guthrie, Okla., has had a full-time employee dedicated solely to patient billing for several years. She attends seminars provided by the Medicare carrier, reads newsletters and basically keeps herself informed of the requirements for ems billing.

The city decided to enlist our services in providing patient billing with the hopes of seeing an increase in collections, but we failed to improve on the performance of the full-time, experienced employee. Therefore, due to the expense, time and training already involved with the full-time employee and the fact that an increase in collected revenue wasn't seen, the city opted to continue using the employee for this service.

The city also felt it was important, and I agree, that patients have a "face" to talk to when asking billing questions or making a payment on their account. Even though I'm employed with many services across the country, I'm happiest when the service collects and posts their own payments. Customer service doesn't begin and end in the back of the ambulance. For all intents and purposes, patients have no idea their billing is being done out of town or out of state.

Whether you choose to handle billing internally or outsource it, you need to make a commitment for your decision to be a successful one. In both situations, it's the responsibility of everyone involved to learn the rules and regulations regarding patient billing. The industry is constantly changing, and ambulance services can't afford not to take the billing seriously.

ems provides patient medical care, just like hospitals, physicians or durable medical equipment businesses, and these agencies should be compensated and treated as such. Fair fees and accurate billing for your patients are, in reality, the final destination of their transport.