(A) Application.
(1) An application for without charge service will be taken when a patient requests without charge service only after credit information is taken and it appears that the patient may be eligible for without charge service. Staff may request without charge service for patients whose financial ability to pay is questionable. A signed application must be on file in order for an account to be approved for without charge service.
(2) If credit information has not been documented and the application will be based on income, a current credit information sheet shall be completed.
(3) Upon receiving the application, the billing service will review the application and make recommendations to the Director according to the eligibility criteria set forth in division (B) below.
(B) Eligibility. A patient will be eligible for consideration for without charge services if he or she meets any of the following and has shown proof that he or she has met any recommendations by billing staff.
(1) Annual income is below the Federal Poverty Guidelines.
100% of Poverty Level Medicaid Scale
|
100% of Poverty Level Medicaid Scale
| |
Size of Family | Monthly Income |
1 | $776 |
2 | 1,041 |
3 | 1,306 |
4 | 1,571 |
5 | 1,836 |
6 | 2,101 |
7 | 2,366 |
8 | 2,631 |
Each additional person | 265 |
(2) Eligible for Kentucky Medicaid and has no other identifiable means of making payment for the balance of services not covered by KMAP.
(3) Eligible for Kentucky Medicaid must apply.
(4) In addition, a patient shall be considered for without charge service is any in- depth financial investigation reveals any of the following:
(a) The is no ability to pay or available assets.
(b) Patient has expired and has no distributable estate.
(c) All available assets are committed to some other essential cause.
(C) An award letter will be sent to the requester informing him or her that he or she has been approved, approved conditionally, delayed for further information, or denied. Patients who have had their accounts approved will not be sent a bill. Bills will be continued until such time that the account has received the approval of the Director of the Ambulance Service or his or her designee where applicable as stated in the without charge policy.
(D) Exceptions. The Ambulance Service will reserve the right to deny full or partial without charge services to anyone who:
(1) Does not qualify under the above guidelines.
(2) Does not follow through with any referral made by Ambulance Service billing staff to an outside agency in attempting to obtain payment from a government source such as Medicaid.
(3) Abuses/misuses the system.
(4) Does not have a medical condition which is determined to be an emergency that requires ambulance transportation.
(5) Requests non-emergency transportation but does not have a medical condition that precludes other means of transportation.
(Ord. 0-04-020, passed - -04)
The City of Pikeville Ambulance Service billing rates are set as follows:
Item or Application of Device | Price |
Item or Application of Device | Price |
Mileage | $20.00 |
Base rate emergency | $2,000.00 |
Base rate non-emergency | $1,000.00 |
Base rate return trip after receiving medical treatment when medically necessary | $600.00 |
Oxygen | $45.00 |
Waiting time per hour after one hour | $100.00 |
Extrication equipment for all type and technical rescue (when used) | $600.00 |
Trauma disposable supplies | $250.00 |
Basic life support disposable supplies | $150.00 |
The following forms shall be the standard form adopted by the city and shall be used for all ambulance runs.
CITY OF PIKEVILLE AMBULANCE SERVICE RUN#
SCENE MILEAGE
DESTINATION MILEAGE
(_) Mileage
(_) Base Rate, Emergency
(_) Base Rate Non-Emergency
(_) Oxygen
(_) Waiting time per hour after 1 hour
(_) Extrication equipment of all types and Technical Rescue (when used)
(_) Trauma \ Disposable Supplies
Trauma\Disposable Supply Protocol
When you have a patient that gets 2 or more of the following items from your unit there will be a "Trauma\disposable charge".
(Please Circle each item used)
Items:
Bag valve mask
Combo pads
Combi-tube
Splinting (all types)
Mast trousers
C-collar
CID
Long Spine Board Kendrick's Extrication Device
Notes
Run#
INSURANCE INFORMATION
Responsible Party SS#
Medicare UMWA
Medicaid Black Lung
Commercial Carrier (or) Worker's Compensation
Address Policy#
Group
Commercial Carrier (or) Worker's Compensation
Address Policy#
Group
Auto Insurance Carrier
Address Phone#
Agent's Name
Insured's Name Claim #
Insured's Policy #
NON-EMERGENCY TRANSPORT AUTHORIZATION
Medical Transportation services were provided on / / for the patient named below: by The City of Pikeville Fire Department Ambulance Service.
I verify the patient named below was at my office/facility to receive a medical service on / /
(Medical Provider Signature)
I certify that I have received the above described services by The City of Pikeville Fire Department Ambulance Service.
(Recipient Signature)
(Ord. 0-04-020, passed - -04; Am. Ord. 2008-008, passed 1-28-08; Am. Ord. 0-2013-007, passed 4-8-13; Am. Ord. 0-2017-27, passed 9-25-17; Am. Ord. O-2024-04, passed 6-10-24)
(A) Uncollectible accounts policies and procedures.
(1) The Ambulance Service shall develop policies and procedures which will appropriately and uniformly identify uncollectible accounts among the citizens of Pikeville.
(2) It shall be the policy of the Ambulance Service to provide, without charge, ambulance transportation to those that have an essential need for emergency or non-emergency transportation but are unable to pay for such transportation. The awarding of without charge services will be based on a set of consistent criteria and will be available to all recipients of service.
(3) WITHOUT CHARGE SERVICE shall be defined as ambulance transportation, either emergency or non-emergency, which has been determined as medically necessary by the patient’s physician, that is given without the expectation of payment, as a result of an in-depth financial investigation.
(4) The Ambulance Service will budget without charge services of an amount not to exceed three percent (3%) of gross patient service revenues or whenever possible to do so without jeopardizing its own financial stability.
(5) The procedure for application for without charge services shall be drafted and approved by the administrative staff, city officials. A copy of such shall be attached to or included with Ord. 0-04-02, passed - -04.
(6) The Director shall not approve any account adjustment which has not met the criteria of established procedures.
(7) The Director or his or her designee may approve applications for without charge service after review and recommendation of billing staff, subject to the following limitations:
(a) Accounts falling within Federal Poverty Guidelines or extenuating circumstances could be discounted fifty percent (50%) to one hundred percent (100%) at the discretion of the designated authority.
(b) Accounts in which total adjustment would be one thousand dollars ($1,000.00) or less.
(8) Accounts requiring authorization of the City Manager and authorization of the Director:
(a) Accounts which are considered exception to routine policy and procedure.
(b) Accounts in which the total adjustment would be one thousand dollars and one cent ($1,000.01) or greater.
(9) Billing staff may make no ledger adjustment for without charge cases without appropriate documentation of application, conforming to the above guidelines.
(B) Write-offs.
(1) All write-offs are at the discretion of the City of Pikeville Ambulance Service with the exception of the following:
(a) Medicaid. All providers who participate with Medicaid are required to write-off the difference of the allowed amount and cannot bill the patient.
(b) Medicare. All providers who participate with Medicare are required to write-off the difference of the allowed amount and cannot bill the patient. Medicare guidelines require all providers “reasonably attempt” to collect from the patient their twenty percent (20%) copay. After three (3) statements are sent to the patient, this is a “reasonable attempt.” If the patient has not paid by three (3) months after they have been billed, they are not likely to pay. (Need to be looked at to decide action.)
(c) Private insurance. Once the insurance has paid their portion, the patient is immediately sent an itemized bill for the balance due. After the third statement is sent, a phone call is made to set the patient’s account on a payment plan. If this effort is not successful, the account needs to be looked at to determine if it should be turned over to a collection agency or place a block on the patient’s credit.
(d) Self-pay patients. The first bill sent is an itemized bill. The next two (2) are statements. A phone call is then made to try to set the patient’s account on a payment plan. If this effort is not successful, the account needs to be looked at to determine if it should be turned over to a collection agency, or place a block on the patient’s credit.
(e) Homeless shelter patients. If the patient has insurance coverage, accept what the insurance pays and write-off the balance as “uncollectible.” If the patient does not have insurance, send one (1) itemized bill. If no response, write-off the balance as “uncollectible.”
(f) Accounts that are over eighteen (18) months due with balances less than fifty dollars ($50.00) can be looked at by the Director for write-off or turned over to collection process at his or her discretion.
(g) Invalid addresses. If a correct address cannot be obtained or resolution for this type of account cannot be accomplished within one hundred twenty (120) days, it is to be placed on patient’s credit report.
(Ord. 0-04-020, passed - -04)