One Emergency. Two Ambulance Rides.
Written By: Asbel Montes, Co-Founder & Managing Partner, SGS
Over the last few months, I've written a three-part series on a question that sounds simple and isn't: who gets to decide what counts as an emergency?
Part one looked at three systems that each answer that question differently. Medicare asks whether a transport was medically necessary and reasonable, and it asks after the fact, from a chart, not from the patient. EMTALA asks whether a hospital's obligation was triggered, based on where inside the hospital care was requested. The GAPB Advisory Committee, which I chaired, built a third answer: a prudent person standard centered on what the person calling 911 reasonably believed in the moment.
None of the three was built with the other two in the room.
For part two, I asked Dr. Nicholas Cozzi, EMS Medical Director and emergency physician at Rush University Medical Center, to take the other side of that 911 call. He put it plainly: "A transfer isn't a courtesy consultation. It's the next step in that patient's care." Stabilized and safe are not the same thing. In rural America, where the nearest specialty center can be hours away, every delay is borrowed time, and as Dr. Cozzi said, a patient didn't choose their zip code.
Part three puts the solution on the table, because it already exists. I want to be precise here. The Committee's prudent person standard says a payer cannot use the outcome to relitigate the call. Its emergency interfacility transport definition treats the second ambulance ride as a continuation of the same emergency, not a separate claim that's harder to justify. Both were adopted without recorded opposition, by people who agreed on very little else in that room. That's a rare agreement in our world.
They are recommendations, not law. Eighteen months after the report went to Congress, nothing has moved.
Clear is kind. Unclear is unkind.
Here's why this matters for your revenue cycle today. The second leg of an emergency doesn't only raise coverage questions. It raises third-party liability questions too.
Think about a patient in a severe motor vehicle accident. They're brought to your emergency department, stabilized, and then transferred for a higher level of care. Do you have a process that catches the accident on the first claim? Does it follow that patient into the continuation of that claim after the transfer? If your TPL process stops at the first hospital, so does your recovery.
Go deeper:
Read the full series: What Counts as an Emergency? | Why "Stable" Isn't the Finish Line | The Committee Already Answered the Question
Watch Dr. Cozzi on the Team Summit Special Edition of The Leadership Lab, now streaming: Here.
Want to know whether your TPL process follows the patient past the first hospital? We can help.
