Audit Report on Ambulance Transport Billings Provided by R1 RCM Inc. for the Fire Department of the City of New York

Executive Summary

The Fire Department of the City of New York (FDNY), the largest fire department in the United States, protects the lives and property of New York City (City) residents and visitors as first responders to fires, medical emergencies, and conditions threatening public safety, including natural disasters and terrorist acts. FDNY, through its Emergency Medical Services (EMS), is also the City’s primary provider of pre-hospital emergency care and ambulance transport. The New York City Charter grants FDNY “the power and authority to provide general ambulance services, emergency medical services and other response services necessary to preserve public health, safety and welfare, and to perform any functions relating to the provision of such services.”

FDNY EMS responds to over one million calls for medical assistance each year through the City’s emergency 911 telephone system. Once they make contact with a patient, FDNY EMS crews utilize mobile tablets to enter and document pertinent information about each patient into an electronic pre-hospital care report (ePCR),^[1] whether or not they transport the patient to a hospital. That information is then uploaded into FDNY’s Health EMS system (HEMS).

The Rules of the City of New York authorize FDNY to charge its patients and their insurers for EMS ambulance transport service provided through the City’s 911 system to help defray the City’s cost of providing these services. FDNY has a contract with Advance Data Processing Inc., d/b/a Intermedix for the provision of ambulance transport invoicing and collection services for a seven-year term ending in January 2022. On May 8, 2018, R1 RCM Inc. (R1) acquired Advance Data Processing Inc.

We conducted this audit to determine whether R1 is performing its abovementioned services in accordance with its FDNY contract.

Audit Findings and Conclusion

R1 generally adhered to its contractual requirements related to ambulance transport invoicing and collection services. Our review of a sample of 254 records from HEMS for transports occurring in Fiscal Year 2018 found that R1 appropriately created and billed patient accounts for those ambulance transports. Specifically, we found that R1 billed amounts at the correct level of service, for the provision of oxygen, and for mileage, and that it made timely submissions of claims and invoices to insurance companies and self-payers, respectively, in accordance with the provisions of the contract.

However, the audit identified several errors that indicate areas of weakness in R1’s and FDNY’s procedures that should be strengthened. Specifically, we found that R1 incorrectly applied three patients’ payments by paper check to the wrong patients’ accounts. Compounding two of those three errors, R1 inappropriately referred one paying patient’s account to R1’s collection attorneys and erroneously invoiced another patient for a charge the patient had already paid, resulting in a double-payment.

We also found that FDNY’s HEMS did not timely export 213 ePCRs to R1’s billing system, a failure that FDNY discovered as a result of our audit—21 months after EMS delivered the associated services. The late discovery that the 213 service-records had not been imported into R1’s system foreclosed FDNY’s opportunity to have R1 bill $153,844 for 165 of those service-records, all involving ambulance transports, because FDNY deems such charges billable for only one year from the date of service.

Audit Recommendations

Based on the audit findings, we make the following five recommendations:

FDNY should:

1. Institute policies and procedures to ensure, and document R1’s written confirmation, that all ePCRs are successfully and timely exported from HEMS into R1’s billing system.
2. Update its policies to include criteria for processing of accounts that were exported and/or imported outside of the timely filing period.
3. Ensure that R1 continues to perform its due diligence in accordance with the Contract to determine the patients’ demographics in any instance in which they are missing from the ePCRs.
4. Ensure that R1 develops a review and quality assurance protocol to ensure that it applies payments received in paper check form to the correct accounts.
5. Ensure that R1 reviews and compares the daily receipt import volume of ePCRs in its billing system with FDNY’s daily export volume from HEMS to determine whether all ePCRs recorded in HEMS were successfully transferred to R1.

Agency Response

In its response, FDNY officials agreed with all five of the audit’s recommendations and stated they have “already taken steps to implement some of them.”

[1] The electronic Pre-hospital Care Report (“EPCR”) is a document to be used by FDNY personnel whenever an ambulance responds to a call and patient contact is made.