Item H3
BOARD OF GOVERNORS
FIRE AND AMBULANCE DISTRICT 1
AGENDA ITEM SUMMARY
Meeting Date: May 15. 2002
Division: Public Safety
Bulk Item: Yes
No X
Department: Emergency Medical Services
AGENDA ITEM WORDING:
Approval of Resolution authorizing the write off of EMS Accounts Receivable, in the total amount of
$213.36, and approval for Mayor to execute Provider Agreement Form
ITEM BACKGROUND:
The attached Resolution requests to write off the balance of the patient accounts that are listed on
Exhibit A, in the total amount of$213.36.
In the case of Herminio Camejo, a request for settlement was received from Clarendon Healthy Kids
Program, a State funded health care program for indigent children. The County Attorney's Office
reviewed the request and advised that it would be prudent to accept the amount they have offered as
payment as full, as it is unlikely that any other resource for payment exists. Execution of the attached
Provider Agreement Eorm is required.
~
In the case of Patricia Matthies, there was an unresolved issue with the treatment she received;
therefore, her transport record was under review. In the interim, due to a clerical error, Ms, Matthies'
insurance company was billed. Payment was subsequently received, leaving an outstanding balance of
$66.16.
PREVIOUS REVELANT BOCC ACTION: None.
CONTRACT/AGREEMENT CHANGES: This is not a contract.
STAFF RECOMMENDATIONS: Approval.
TOTAL COST: N/A
BUDGETED: Yes
No
COST TO COUNTY: N/ A
REVENUE PRODUCING: Yes
NoX
AMOUNT PER MONTH_ Year
DIVISION DIRECTOR APPROVAL:
Risk Management N/ A
APPROVED BY: County Attorney YES
~
DOCUMENTATION:
Included X
To Follow
Not Required
~SPOSITION:
AGENDA ITEM #
/N
Emergency Medical Services
RESOLUTION NO. -2002
A RESOLUTION OF THE BOARD OF GOVERNORS OF THE
FIRE AND AMBULANCE DISTRICT 1 OF MONROE COUNTY,
FLORIDA, AUTHORIZING THE WRITE-OFF OF EMS
ACCOUNTSRECENABLE
WHEREAS, Monroe County Emergency Medical Services provides ambulance service; and
and
WHEREAS, attempts to collect the full amount from the service recipients have been made;
WHEREAS, it has been determined that further collection efforts are fruitless and would only
incur additional costs to continue to bill the recipient as the insurance coverage afforded said recipient
is not sufficient to cover all recipient's medical damages: and recipient continues to suffer great
financial hardship; now, therefore
BE IT RESOLVED BY THE BOARD OF GOVERNORS OF THE FIRE AND
AMBULANCE DISTRICT 1 OF MONROE COUNTY, FLORIDA:
Service recipients listed on attached Exhibit A accounts receivable in the amount of$213.36 be
deleted from the County's Emergency Medical Services Department accounts receivable list.
PASSED AND ADOPTED by the Board of Govemors of the Fire and Ambulance District 1 of
Monroe County, Florida, at a regular meeting of said Board held on the day of
, 2002.
Chairperson Yvonne Harper
Commissioner George Neugent
Commissioner Nora Williams
Commissioner Murray Nelson
Commissioner Dixie Spehar
(SEAL)
BOARD OF GOVERNORS OF THE
FIRE AND AMBULANCE DISTRICT I OF
MONROE COUNTY, FLORIDA
Attest: DANNY L.KOLHAGE, Clerk
By:
Mayor/Chairperson
By
Deputy Clerk
APPROVED AS TO FO
AND ~Al SUFFICf
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HeRS
HEALTH CARE RECOVERY SYSTEMS
31S1 AirwAY Ave., Building 1-3, Suite F, Costa Mesa, CA. 91626 .. Phone 714-556-4255 Fax 714-556-4280
PROVIDER AGREEMENT FORM
Date: March 6, 2002
TO: Darice,
PROVIDER: Monroe City Ems.
F~: 305-289-6336
PHONE:
305-289-6004
PATIENT: Camejo, HermJnlo
Date of Service: 11/18/01
Patient Acct: 41140701
PATIENT ID:
590-24-4024
. Current Billed Charges: $588.95
Group: Clarendon Kids, FL
Dear: Darice,
This agreement confirms that Monroe City EMS. #596000749 agrees to the revised S
amount for services on the above patient to be $441.75
There will be no billing to the primary payor, insured or the patient for the difference between the billed
charges and the agreed upon amount for the services rendered for this episode of care except for tbe insured
co-pay, deductibles and co-insurance based on tbe agJ'eed upon amount. The provider also agrees that the
bill will be processed by the payor subject to eligibility, co-payment, deductibIes, insurance plan limits,
maximums and utilization review requirements as defined in the patients insurance plan docwnent.
This agreement I. in Ueu of any proposed audit!. The above claim will qualify for prompt processing
nd ill be 15 business days.
Manager
John Ralph!
Health Care Recovery Systems
Signature Date
Authorized Representative of Provider
Printed Name
Title
Please silO above and FAX. to HOtS at 714-556-4180 or call me at 714-556-4255. Thank you for
your time and consideratJon of the claim.
BY
AN~A trITON
tj ~b/o)_
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n"'TF
HEALTH CARE RECOVERY SYSTEMS
PHONE: 714-556-4255
FAX: 714-556-4280
FAX COVER PAGE
TO:
Darice @ Monroe City EMS.
FAX#:
305-289-6336
FROM:
John Ralphs I Peggy Thompson
DATE: 3/6/02
PATIENT:
Camejo, Herminio #590-24-4024
PAGES SENT (Including Cover): 2
COM:MENTS:
We represent the Clarendon Healthy Kids Program - a state funded health
plan for indigent children of Florida. On the date of service of the attached
claim Monroe City EMS. was not contracted with the state plan, however,
the state has authorized us to pay these out of network claims and not return
them to the patient. The plan has asked that in return for paying these
claims, we be allowed to use a normal network discount that we would
receive from our contracted providers. The state will pay this claim at
100% if you will allow us to use the network discount on the attached
provider agreement. Please review the attached agreement and if it meets
with your approval, sign and fax back to me today and we can process this
claim for payment at once.
Thank you for your support of this program for the kids of Florida.
Thank You!
John Ralphs
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