1、Designation: F 1493 93 (Reapproved 2003)Standard Guide forFinancing and Financial Accountability of MedicalTransportation Systems1This standard is issued under the fixed designation F 1493; the number immediately following the designation indicates the year oforiginal adoption or, in the case of rev
2、ision, the year of last revision. A number in parentheses indicates the year of last reapproval. Asuperscript epsilon (e) indicates an editorial change since the last revision or reapproval.1. Scope1.1 This guide establishes guidelines for understanding thefinancing of medical transportation systems
3、. It identifies fac-tors affecting financing, system design and performance re-quirements, revenue sources, financial accountability and man-agement, and requirements for financially efficient systems.2. Referenced Documents2.1 ASTM Standards:F 1177 Terminology Relating to Emergency Medical Ser-vice
4、s23. Terminology3.1 Definitions of Terms Specific to This Standard:3.1.1 patient transport pricedetermined by summing allcosts related to patient transports, to include all non allowedcharges and contractual allowance and adjusted by any revenuegenerated by any subsidies, contributions and subscript
5、ionfees. The resulting amount is divided by the total number ofpatient transports to determine the patient transport price.3.1.2 medical transportation system(see TerminologyF 1177 for the definition of this term.)3.1.3 medical transportation services(see TerminologyF 1177 for the definition of this
6、 term.)4. Significance and Use4.1 ManagementSound fiscal management is essential forall medical transportation systems. Without sufficient financialresources, a system will fail to consistently achieve its objec-tives. Therefore, finance is a primary responsibility in allsystems; be they hospital ow
7、ned/operated, private, public orvolunteer organizations, or any combination thereof.4.2 Cost DeterminationThis guide is designed to accu-rately determine actual and imputed costs of providing ambu-lance service. It provides methodology for understanding thevalue of services rendered and a basis for
8、realistic industry-wide comparisons.4.3 Cost AccountingIt is recognized that medical trans-portation services frequently are a part of a larger organization.However, the proper use of this guide mandates that all costs,real and imputed, directly or indirectly related to providingambulance service, r
9、egardless of organizational structure, betotally and accurately accounted for through the use of gener-ally accepted accounting principles.4.4 ApplicationThis guide, as part of the ASTM Stan-dards and Practices, shall apply in its entirety whenever theentire document, or any part thereof, is used by
10、 any govern-mental authority to establish, operate, manage or regulate thedelivery or payment for medical transportation services.5. Environmental Factors5.1 Several significant factors of a given service area affectits systems resources and related costs. They require carefulexamination and analysi
11、s. Understanding these factors willenhance the ability of those who direct, administer, manageand/or regulate medical transportation systems to more accu-rately determine anticipated needs and evaluate actual costs.5.2 TerrainAreas with mountains, valleys, waterways andbridges, and so forth, will us
12、ually be less accessible and requiremore resources resulting in reduced efficiency and a higherpatient transport price.5.3 Roads and HighwaysOutdated and dangerous designof roads create hazards. These hazards create more demand forservice and thus require a greater concentration of resources.The ext
13、ra resources increase system costs.5.4 WeatherSystems subject to extreme weather condi-tions (that is, cold and snow, heavy rain and rock/mud slides,hurricanes, heat and dry conditions, wild/forest fires, and thelike) will need seasonal or periodic plans to meet area needsduring such extremes. Maint
14、enance of proper response plansand participation therein is a cost factor to the system. Duringsuch times maximum resources are required and systemefficiency is reduced resulting in higher overall patient trans-port costs.5.5 Population DensityAreas of high population densitygenerate higher call vol
15、ume and allow greater flexibility inutilization of resources resulting in lower overall patienttransport costs.5.5.1 DemographicsAreas with population characteristicswith high concentrations of the elderly and economically1This guide is under the jurisdiction of ASTM Committee F30 on EmergencyMedica
16、l Services and is the direct responsibility of Subcommittee F30.03 onOrganization/Management.Current edition approved Sept. 10, 2003. Published October 2003.2Annual Book of ASTM Standards, Vol 13.02.1Copyright ASTM International, 100 Barr Harbor Drive, PO Box C700, West Conshohocken, PA 19428-2959,
17、United States.disadvantaged, or both will result in higher call volume and agreater demand on resources to meet the needs of theseportions of the total service area.5.6 Natural/Man Made DisastersSystems subject to un-predictable events of extreme consequences (for example,earthquakes, airplane crash
18、es, structural fires, hazardous mate-rial incidents, and the like) will need emergency preparednessplanning to meet area needs during disaster events. Mainte-nance of proper response plans and participation in exercise arecost factor to the system. During disasters maximum resourcesare required and
19、system efficiency is reduced resulting inhigher overall patient transport costs.6. System Design Factors6.1 Service AreaIt is generally more economical for amedical transportation system to serve a larger population.Systems which provide a larger volume of transports within agiven area will benefit
20、from the inherent economies of scaleand generate a lower average cost per transport.6.2 Medical Transport ProvidersThe number of medicaltransport providers in a service area directly influences the costper transport. Duplication of resources by multiple providerswithin a service area can negatively
21、impact economies of scale.6.3 Health Care FacilitiesThe number and location ofhospitals, nursing homes, and the like, will influence costs. Asignificant number of transports to hospitals outside the servicearea can increase costs. A larger ratio of nursing home beds toa given general population can
22、result in higher economies ofscale than a smaller ratio and thereby lower costs.6.4 Start-Up CostsSufficient funds must be available toensure the success of initial start-up, or expansion of anexisting service. To determine the required level of funding,consideration must be given to the following;6
23、.4.1 Offce/Service FacilityItems to be included arebuilding, office equipment, furniture and fixtures, computers,and so forth.6.4.2 EquipmentItems to be included are ambulances,administrative vehicles, communication equipment, medicalequipment and supplies, and so forth.6.4.3 InventoryItems to be in
24、cluded are sufficient levelsof supplies for on-going operations of ambulance services andoffice functions for the period of time it is expected to take toestablish cash flow to support on-going operation.6.4.4 PersonnelItems to be included are expenses relatedto recruiting, hiring, training, salarie
25、s and benefits.6.4.5 InsuranceActual premium paid, or imputed costsfor self-funding.6.4.6 Working CapitalFunds adequate to support overalloperations until such time as sufficient cash flow is established.6.5 Jurisdictional ResponsibilitiesJurisdictions exist atthe federal, state, regional, and local
26、 level which have animpact on the operation of each EMS provider and the EMSsystem. They may include the following:6.5.1 EMS Regulations/LegislationEMS regulations andlegislation are usually passed at the state or local units ofgovernment. They are usually influenced by EMS guidelinesrecommended at
27、the federal level.6.5.2 LaborFederal labor laws cover issues related toHealth 9.2.1 AssetsTangible or non-tangible items of value to thesystem.9.2.1.1 Current AssetsAssets whose value will be used orrealized within a twelve month (fiscal year) period (forexample, cash, accounts receivable, pre-paid
28、expenses, and thelike).9.2.1.2 Fixed AssetsAssets which will have value to thesystem at the end of a twelve month (FY) period.9.2.1.3 Other AssetsAssets whose length of value isindeterminable (for example, goodwill, tax credits, utilitydeposits, and the like).9.2.2 LiabilitiesObligations owed by the
29、 system.9.2.2.1 Current LiabilitiesObligations which will gener-ally be paid within a twelve month (FY) period (for example,accounts payable, accrued payroll expenses, current portion oflong-term debt, and the like).9.2.2.2 Long-Term LiabilitiesObligations owed by thesystem whose payment term extend
30、s beyond a twelve month(FY) period (for example, bank notes, bond payments, ad-vances from stockholders, and the like).9.2.2.3 Other LiabilitiesObligations whose paymentterms are indeterminable (for example, deferred taxes, and thelike).9.2.3 EquityThe value of the difference between totalsystem ass
31、ets and liabilities which reflect the net value of thesystem.9.2.3.1 Paid in CapitalInitial or additional investment inthe system.9.2.3.2 Retained Earnings/ReservesThe total net income/loss which remains in the system at a specific point in time.9.3 Income StatementThe measure of the financial perfo
32、r-mance of the system over a period of time.9.3.1 RevenueTotal income from all revenue sources, lessrevenue reductions.9.3.2 Operating ExpensesTotal costs, real or imputed,which relate to producing the service (for example, servicerelated salaries and associated costs, supplies, vehicle mainte-nance
33、 and depreciation, insurance, and the like).9.3.3 General and Administrative ExpensesTotal costs,real or imputed, which relate to administration and promotionof the service (for example, administrative/clerical salaries andassociated costs, advertising, computer systems, professionalfees, and the li
34、ke).9.3.4 Income TaxesFederal, state and local income taxesrequired of providers who are not tax exempt.9.4 Reserve and Working CapitalAn annual capital andoperating budget is an estimate of yearly expenses. As it isimpossible to predict all expenses and occurrences, a reservefund is an appropriate
35、protective mechanism. This fund shouldbe an amount which can cover most unexpected financialemergencies. Another important component is a planningbudget allowance for sufficient funds to pay bills when due,recognizing that revenue income can be variable, inconsistent,and periodic. This is referred t
36、o as working capital and must besufficient to pay bills until collections are received. Insurancecompanies and other parties often take several weeks toprocess reimbursements. Some services receive once-a-yearsubsidies. Careful planning is required to assure that thesefunds last until the next years
37、 receipt of revenue. For subsi-dized services a subsidy advance may be necessary to provideworking capital.9.5 Revenue AccountingPrecise accounting practicesmust be established and routinely maintained with respect tospecific categories of revenue and reductions thereof. Thisinformation is necessary
38、 for system directors, administratorsand managers to assess income performance and make deci-sions when revenue must be increased, or decreased, and whichrevenue source, or reduction, or combination thereof, must bealtered to achieve the desired result.F 1493 93 (2003)39.6 Accounting MethodologyThe
39、accrual method of ac-counting, as identified in the General Accepted AccountingPrincipals,3is the recommended way of determining costs andmaintaining financial records.10. Management Issues Related to Establishing thePatient Transport Price10.1 Total Patient Transport CostThis is comprised of allope
40、rating and administrative costs of the system (including baddebt), direct or indirect, real or imputed, including allowancesfor reserves/profit.10.2 Adjustment for Non-Allowed ChargesAdd to thepatient transport cost the total amount of non-allowed chargesby Medicare or Medicaid.10.2.1 Non-allowed ch
41、arges are amounts which, by law,cannot be billed, as a result of accepting assignment fromMedicare or Medicaid. This occurs when a provider acceptsassignment, and thereby agrees that what Medicare determinesas the allowable payment, and Medicaid pays, is payment infull for services rendered.10.2.2 A
42、 provider who accepts assignment on Medicareclaims, will receive only a percentage of the charges billed.The providers actual charge, minus Medicares allowedcharge, if lower, equals the non-allowed charge. The allowedcharge is based upon the profile established by the Medicarecarrier, within a given
43、 region, for a particular provider, and isreimbursed as 80 %. Medicaid reimbursement depends on thepolicies of various state programs.10.2.3 Calculation of projected non-allowed charges is de-termined by deducting a historical percentage from grossMedicare and Medicaid billings. This percentage will
44、 vary byprovider, its Medicare profile, its ability to manage billingpolicies, a given service area and state. This calculation mustbe made as a factor in determining the patient transport price.10.3 Adjustment for Contractual AllowancesAdd to thepatient transport cost and non-allowed charges the to
45、tal amountdiscounted to specific users.10.3.1 Calculation of contractual allowances is determinedby deducting the negotiated amount/percentage from grosscharges to specific users with whom agreements exist. Thisamount will vary by provider, its ability to negotiate specialagreements and the service
46、area. This calculation is a factor indetermining the patient transport price.10.4 Adjustment for SubsidySubtract from the total pa-tient transport cost, non-allowed charges and contractual al-lowances the amount of subsidy.10.4.1 Many service areas need subsidies to achieve desiredlevels of availabi
47、lity and performance requirements. They maygenerate abnormally high patient transport costs, based ongeographics, population density, demographics or a combina-tion thereof, desired results. These areas must provide subsidyto offset these unique costs that are results of these factors.However, subsi
48、dy should not be used to arbitrarily reducepatient transport price beyond considerations for these factors.10.4.2 Systems which subsidize patient charges by chargingless than cost, by design, limit funds otherwise available fromthird party payers.10.4.3 The level of subsidy should have no relationsh
49、ip tosystem efficiency, but does have a direct effect on the reductionof the unadjusted patient transport price. Reductions in theadjusted patient transport price will affect future reimburse-ment levels from third party payers.10.4.4 Once the patient transport cost is established theeffect of subsidy must be calculated. The provision of subsidyfor ambulance service affects the patient transport price.10.4.5 A variance in subsidy is not equivalent to a similarchange in the patient transport price. Allowances for bad debtmust be made (
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