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and concise information. Staff will continue to monitor the expenses of the service with every effort being taken to limit expenses while continuing to provide the high level of service our citizens have come to expect and demand. Indian River County provides an Advanced Life Support (ALS) level of service to every citizen on every call received from the E911 System in the County. Since the County is only utilizing revenue from third party billing to offset tax revenues needed for the service, staff feels that each and every run in the County should be billed for the level of service provided. This is being done in other jurisdic- tions in the state and was being done by Indian River Memorial Hospital prior to the County service. An average bill of $311.42 is submitted to Medicare for an ALS patient on an average EMS run versus $90.00 for a BLS run. It should be noted that 66% of all billings are Medicare related. Medicare pays an average of $140.84 of the $311.42 or 45% of the amount billed for a typical ALS run. This percentage rises to 55% of the amount billed if the patient has secondary insurance. The average secondary insurance amount collected is $30.00, largely due.to changes in Medicare wherein once Medicare has valued the medical service costs (80%), secondary insurance is limited in what they have to pay. In cases of automobile accidents, 100% collections are being achieved from insurance carriers. An average of seven (7%) percent or approximately 483 runs out of 6,908 ALS patients (since 2/1/89) are completely unin- sured and the County receives no revenue from these runs. Some external factors have had an adverse impact on the third party billing approach mostly dealing with Medicare system changes. Since the County assumed the ALS service, Medicare has eliminated charges for some medical supplies and placed a value on medical costs which allows secondary insurance companies to pay only a fraction of the costs remaining for the service after Medicare pays the statutory 80%. Staff also is not precluding a percentage cut of approximately 2% in Medicare revenue in that Congress has imposed some budget restrictions due to the Graham -Rudman Act and across the board cuts in federal budgets could potentially be mandated. To assist in reducing any shortfall that may occur, staff recommends that the Board of County Commissioners approve implementing the following: 1. Approve and authorize staff to bill every run at the ALS fee schedule. The County provides an ALS level of service on every run and as stated above, this is being done in other jurisdictions in the state; 2. Approve a fee of 550.00 an hour for a minimum of two hours for the County RLS to provide EMS personnel and equipment at special events not community oriented or sponsored. Additional revenue in the range of approximately $96,000 would be generated annually if the County billed all runs at the ALS service level according to run history since Febru- ary 1, 1989. While there may still be some shortfall in this fiscal year, staff feels that it is somewhat early to make that determination. Staff does commit to living within established budgets as approved by the Board and will continue to monitor both the expense and revenue for the ALS EMS service. 17 BOOK